Family therapy an overview goldenberg pdf

Family Therapy Vs. Feminist Family Therapy Approach

Title of book: Family Therapy: An Overview (9th Edition) Author of book: Irene Goldenberg, Mark Stanton, Herbert Goldenberg Chapter Title: Chapter 3 Diversity in Family Functioning Author of Chapter: Irene Goldenberg, Mark Stanton, Herbert Goldenberg Year: 2017 Publisher: Cengage Learning Place of Publishing: United States of America The copyright law of the United States (Title 17, United States Code) governs the making of photocopies or other reproductions of copyrighted materials. Under certain conditions specified in the law, libraries and archives are authorized to furnish a photocopy or other reproduction. One of these specified conditions is that the photocopy or reproduction is not to be used for any purpose other than private study, scholarship, or research. If a user makes a request for, or later uses, a photocopy or reproduction for purposes in excess of fair use that user may be liable for copyright infringement.

DIVERSITY IN FAMILY FUNCTIONING

African American or a Salvadoran refugee. Gender 1 , culture, ethnicity, and socioeconomic

status must be considered in relationship to one another by a therapist who tries to make

sense of a client family's hierarchical arrangement, for example, or the family's social attitudes,

expectations, or relationship to the majority culture.

Sarmiento and Cardemil (2009) show how ethnic background, socioeconomic status,

and immigration status with the associated issues of acculturation to life in the United

States relate to family functioning and the experience of depression in immigrant Latino

families. They found that poor family functioning and a high degree of acculturative

stress (the stresses associated with living in a new culture) yield higher levels of depres­

sive symptoms, especially among women. The depression among women is also associated

with family-related factors, whereas male depression was more likely linked to other factors,

such as employment and financial stressors. They attributed these differences to the cultural

traditions of marianismo and machismo among Latino women and men, respectively. In

Latino culture, according to these researchers, Latinas (women) are expected to be caring,

nurturing, and self-sacrificing while always prioritizing the needs of family over their own

needs. Women who adhere to these traditions were found to be susceptible to greater family

conflict and to more experiences of depression. Men adhering to the values of machismo,

on the other hand, feel pressure to financially support and otherwise protect their families.

To be fully competent, a therapist must take into account his or her own cultural back­

ground, socioeconomic status, race, ethnicity, sexual orientation, religion, life cycle stage,

and so forth in working with families from different backgrounds, being especially alert to

how these factors interact with those same factors in the client family. This typically requires

clinical training to adopt a contextual lens (Esmiol, Knudson-Martin, & Delgado, 2012).

Christopher, Wendt, Marecek, and Goodman (2014) refer to the need for therapists to adopt

a cultural hermeneutic that facilitates development of "a practical understanding of every­

day lived experience" (p. 4) when interacting with a different culture. See Box 3.1 for an

evidence-based report on how therapist background interacts with client gender.

In the case of gender, both the feminist movement and men's studies have drawn atten­

tion to the effects of sexist attitudes and patriarchal behavior on family functioning. Gender

inequities are being addressed regarding sex-based role assignments within family groups as

well as the wider culture that defines what relationships are possible within families and who

is available to participate in those relationships (McGoldrick, Anderson, & Walsh,_ 1989).

One result of the societal challenge to fixed gender roles and expectations has been a reassess­

ment of family therapy models that were based on men's experiences and value systems, not

recognizing that women's experiences and values might be different. This male perspective

regarding stereotyped gender roles determined what constitutes "healthy'' family functioning

'It is important to draw a distinction between sex (the biological differences between men and women) and gender (the culturally prescribed norms and roles played by men and women). In this chapter we emphasize the latter as an organizing principle of family relationships and as the basis of behavior sociery considers "masculine" or "fem­ inine." Levant and Philpot (2002) note that gender roles are psychological and socially constructed entities, bring with them certain advantages and disadvantages for men and women alike, and perhaps most important from a therapeutic viewpoint, are not fixed but subject to change.

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■ BOX3.1 EYIDENCE-B:ASED F'R:AetlCE Therapists' Background Influences Assessment and Treatment

Hertlein and Piercy (2008) surveyed 508 marriage and family therapists to investigate how treat­ ment decisions might vary in terms of the gen­ der of the client and the background variables (socioeconomic status, race, ethnicity, etc.) of the therapist. The specific clinical issue they ex­ amined was how the therapists understood and treated cases of social media infidelity (when a person in a committed relationship makes con­ tact with someone via social media and engages in behaviors ranging from flirting, to emotional connection, to sexual gratification). The thera­ pists responded to several typical Internet infi­ delity scenarios in which the person initiating the

infidelity was the same for half of one sample.

Investigators also asked the therapist-participants to respond to how they might assess and treat each presenting problem posed by the scenarios. They were asked to evaluate the severity of the problem posed, offer a prognosis, estimate the number of sessions necessary for treatment, and indicate the text to which they would focus indi­ vidually or relationally. The results indicated that there were differences in how therapists assessed and treated clients based on client gender, ther­ apists' age and gender, how religious therapists reported themselves to be, and the extent of the therapists' personal experience with infidelity. The results clearly show how diversity variables affected treatment approaches and outcomes.

in these models, and as a consequence, Philpot (2004) proposes gender-sensitive family therapy that attempts to overcome confining sex-role stereotyping by therapists in clinical interventions. She suggests that therapists be attuned to the gender-role messages that clients (and therapists) grow up absorbing and, perhaps more important, to help clients (and oneself) recognize, label, and challenge sexist-based messages.

There has also been increased attention to the varied perspectives and lifestyles of the different cultural groups that make up our society. These efforts attend to a larger sociocul­ tural context to broaden our understanding of cultural influences on family norms, values, belief systems, and behavior patterns. Attention to multiculturalism has also challenged any previously entrenched ethnocentric views by family therapists of what constitutes a "healthy" family. As Goldenberg and Goldenberg (1999) contend, a family therapist today must take a client family's cultural background into account in order to avoid pathologizing ethnic minority families whose behavior is unfamiliar, taking care not to misdiagnose or mislabel family behavior in the process. This requires the therapist to be aware of how these very same factors helped shape their own personalities and professional capacities.

1 Multicultural and Culture-Specific Considerations Understanding families requires a grasp of the cultural context (race, ethnic group membership, religion, socioeconomic status, sexual orientation) in which that family functions and the sub­ sequent cultural norms by which it lives. Culture-shared, learned knowledge, attitudes, and behavior transmitted from one generation to the next-affects families in various ways, some

DIVERSITY IN FAMILY FUNCTIONING

Recognizing Strengths in African-American Families

It is important for therapists to understand how

different groups understand and experience

their strengths. Bell-Tolliver, Burgess, and Brock

(2009), building on the pioneering work of Robert

B. Hill, interviewed 30 African-American psycho­

therapists who used a strengths perspective in

working with African-American families to iden­

tify those strengths and clarify how to use them

clinically. Hill (1971, 2003) identified five strengths

for this population: (a) strong kinship bonds;

(b) a strong work orientation; (c) adaptability of

family roles; (d) strong achievement orientation;

and (e) strong religious orientations . To these,

Bell-Tolliver and colleagues added (f) increased

willingness of African-American families (than in

Hill's time) to seek therapy, and (g) family struc­

ture. Then the researchers identified strategies

for therapists to consider using the identified

strengths in treatment:

• Utilization of beliefs, attitudes, and strategies for

building trust between therapist and clients that

rely on affirmations, praise, and encouragement

• An appreciation that many clients want ther­

apists to understand the history and current

struggles of African-American families, espe­

cially with respect to racism

• Listening and being curious about strengths

• The use of storytelling

• The appropriate incorporation of spirituality in

the therapy

Both strengths and any notion of what constitutes pa­

thology must be understood as being influenced by

gender and cultural factors.

trivial, others central to their functioning. It is interwoven with our worldview. Language,

norms, values, ideals, customs, music, and food preferences are all largely determined by

cultural factors (McGoldrick & Ashton, 2012).

As family therapists have attempted to apply existing therapy models to previously underserved

cultural groups,2 they have also had to gain greater awareness of their own cultural background

and values and to examine the possible impact of these factors in pathologizing ethnic minority

families whose values, gender roles, discipline practices, forms of emotional expression, and so

forth are different from theirs or those of other cultures (Fontes & Thomas, 1996). Efforts are

underway to develop a culture-sensitive therapy (Prochaska & Norcross, 2014)-one that rec­

ognizes, for example, that the White middle-class cultural outlook from which most therapists

operate (prizing individual choice, self-sufficiency, independence) is not embraced by all ethnic

groups with which those therapists come into contact. In many Asian families, for example,

interdependence within the family is expected, as it is that family members will subordinate

individual needs to those of the family and society at large (McGoldrick & Ashton, 2012).

2According to the 2010 survey of California practicing marriage and family therapists, Riemersma (201 0) reports that 89% were of European-American background, a percentage that has dropped from 94% over 15 years. These therapists indicate that they regularly treat other cultures.

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64 CHAPTER 3

The evolving view of cultural diversity recognizes that members of racial and ethnic groups

retain their cultural identities while sharing common elements with the dominant American

culture (Axelson, 1999). In many instances, ethnic values and identifications may influence

family life patterns for several generations after immigration to this country. Acculturation is

an ongoing process that usually occurs over multiple generations, as families confront chang­

ing gender-role expectations, child-rearing practices, intergenerational relationships, family

boundaries, and so forth common in the dominant culture to which they have migrated.

At the same time, immigrant families often must face changes in social level to lower-status

jobs, ethnic prejudice and discrimination, the acceptance of minority status in the new land,

and in some cases the fear of deportation.

Clearly, family therapists need to be culturally sensitive to the ever-increasing diversity

among client families if they are to deal with such families effectively (Aponte & Wohl,

2000). On the other hand, they must be careful not to blindly adopt an ethnically focused

view that stereotypes all members of a particular group as homogeneous and thus responds

to a client family as if it were a cultural prototype. Here it is useful to note Falicov's (2014)

reminder regarding ethnically diverse groups that a variety of other factors-educational

level, social class, religion, and stage of acculturation into American society, to name but a

few-also influence family behavior patterns. Moreover, individual family members differ

from each other in their degree of acculturation as well as in their adherence to cultural

values (Sue & Sue, 2012).

a

A multicultural outlook champions a general, culturally sensitive approach with families and

urges therapists to expand their attitudes, beliefs, knowledge, and skills to become more

culturally literate and culturally competent (Sue et al., 1998). Culturally competent thera­

pists take client cultural histories into account before undertaking assessments, forming

judgments, and initiating intervention procedures. They assume there is no single theory of

personality applicable to all families but instead urge the adoption of a pluralistic outlook

that calls for multiple perspectives rooted in and sensitive to particular cultures (Prochaska &

Norcross, 2014).

More than learning about specific cultures, many advocates of multiculturalism (Pedersen,

2000; Ponterotto, Casas, Suzuki, & Alexander, 2010) urge the adoption of an open, flexible

attitude about diverse cultures and cultural influences but not one tied to any specific cultural

group. At the same time, they advocate that therapists gain greater awareness of their own

values, assumptions, and beliefs, understanding that these are not absolutes but arise from the

therapist's own cultural heritage. Sue and Sue (2012) emphasize the importance of adopting a

broad viewpoint in working therapeutically with "culturally different" client populations and

learning a set of appropriate intervention techniques suited to diverse clients. See Box 3.3 for

exercises to enhance your multicultural awareness.

Hernandez, Siegel, and Almeida (2009) offer a cultural context model for working with

families from different backgrounds. The model uses three processes to facilitate change in

therapy: (a) the development of critical consciousness, (b) a deepened sense of empowerment,

Cultural Sharing

We generally begin training with cultural shar­ ing to convey from the outset that all clinical in­ teractions require building cultural bridges from different perspectives and to engage students in exploring their cultural backgrounds. We ask stu­ dents in a training group to introduce themselves by: (1) describing themselves ethnically, (2) de­ scribing who in their family influenced their sense of ethnic identity, (3) discussing which groups other than their own they think they understand best, and (4) discussing how they think their own family members would react to being referred for therapy for a psychological problem. At times we use exercises that enable trainees to have mini­ converstations with others in their training group to discuss cultural issues such as:

• Describe something you like most about your cultural background and something you find hardest to deal with.

DIVERSITY IN FAMILY FUNCTIONING

• Describe how your family was "gendered"­ that is , what were the rules for gender behav­ ior, and who in your family did not conform to its gender stereotypes?

• What is your class background, and what changes have you or others in your family made because of education, marriage, money, or status?

• Describe a time when you felt "other" in a group and how you and others dealt with this "otherness."

• Describe what you were taught growing up about race and how your consciousness about this may have changed over time.

(McGoldrick & Hardy, 2008, pp. 453-454)

and (c) accountability. These processes help in four domains of family experience: (a) con­

versational, (6) behavioral, (c) ritual, and (d) community building. By working with fam­

ilies alone and in larger groups of others from similar backgrounds (in both same-gender

and mixed-gender versions), the authors strive to create a collective experience that moves

family systems and individuals within these systems to explore the impact of dominant patri­

archal discourses on the cultural lives of both men and women and, through their heightened

self-awareness, to new levels of empowerment and accountability.

Those family therapists who advocate a culture-specific approach urge more detailed knowl­

edge of common culturally based family patterns of unfamiliar groups. McGoldrick, Gior­

dano, and Garcia-Preto (2005) bring together several dozen experts to provide detailed

knowledge about a wide variety of racial and ethnic groupings. Their description of different

lifestyles and value systems underscores that we are increasingly a heterogeneous society, a

pluralistic one made up of varying races and ethnic groups, as millions migrate here seek­

ing a better life. The majority of the total population growth in the United States between

2000 and 2010 was due to the growth of the Hispanic population; the Asian population had

the highest group percentage increase (43%) and increased to 5% of the total population

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66 CHAPTER 3

(Humes, Jones, & Ramirez, 2011). Similarly, Pedersen, Draguns, Lonner, and Trimble

(2008) offer detailed assistance in working with clients from a substantial range of specific

backgrounds.

One way to assess the impact of a family's cultural heritage on its identity is to learn as

much as possible about that specific culture before assessing the family. This undertaking is

valuable in determining the extent to which its members identify with their ethnic background

and to ascertain the relationship of ethnicity issues to the presenting problem (Giordano &

Carini-Giordano, 1995). Just as it would be a mistake to judge the family behavior of clients

from another culture as deviant because it is unfamiliar, so therapists must also be careful not

to overlook or minimize deviant behavior by simply attributing it to cultural differences.

Taking gender, social class position, sexual orientation, religion, and racial or ethnic

identification into account, a comprehensive understanding of a family's development and

current functioning must assess its cultural group's kinship networks, socialization experi­

ences, communication styles, typical male-female interactive patterns, the role of the extended

family, and similar culturally linked attitudinal and behavioral arrangements (Goldenberg &

Goldenberg, 1993).

Family therapists must try to distinguish between a client family's patterns that are

universal (common to a wide variety of families), culture specific (common to a group, such

as African Americans or Cuban Americans or perhaps lesbian families), or idiosyncratic

(unique to this particular family) in their assessment of family functioning. That is, they must

Suppose this family presented for family therapy. Do you think the race of the therapist would have any impact on the treatment? Why or why not?

DIVERSITY IN FAMILY FUNCTIONING

discriminate between those family situations in which cultural issues are relevant and those

in which cultural issues are tangential, but this requires examination of the ecosystemic con­

text of the family (Falicov, 2014). In this regard, Boyd-Franklin (2002) notes that unlike the

dominant cultural norms, African Americans adhere to cultural values that stress a collective

identity, family connectedness, and interdependence. Her research (Boyd-Franklin, Franklin,

& Toussaint, 2000) with African-American parents reveals their special concerns about their

children, particularly their sons: survival issues such as racial profiling, the disproportionate

number tracked into special education and juvenile justice programs, drug and alcohol abuse,

gangs, violence, and so forth.

Family therapists also must keep in mind that while gaining awareness of differences that

might be attributable to ethnicity or racial characteristics of a specific group is typically help­

ful, there is also a risk in assuming uniformity among families sharing a common cultural

background. Fontes and Thomas (1996) caution that while a culture-specific family therapy

outlook offers useful guidelines, these guidelines should not be considered recipe books for

working with individual families. Even if they share the same cultural background, different

families have divergent histories, may come from different socioeconomic status, or may show

different degrees of acculturation. As an example, these authors observe that members of a

Mexican-American family may identify themselves primarily as Catholic, or Californian, or

professional, or Democrat; their country of origin or cultural background may actually be

peripheral to the way they live their lives. Ultimately, the therapist's task is to understand how

the client family developed and currently views its culture.

Family therapists must exercise caution before using norms from the majority cultural

matrix in assessing the attitudes, beliefs, and transactional patterns of those whose cultural

patterns differ from theirs. Lack of cultural understanding by therapists, especially White

therapists, is frequently cited as a barrier to family therapy in some cultures (Awosan,

Sandberg, & Hall, 2011). The idea of being "color blind" to racial differences is no virtue if

it means denial of differences in experiences, history, and social existence between themselves

and their clients. The myth of sameness in effect denies the importance of color in the lives

of African-American families and thus closes off an opportunity for therapists and family

members to deal with sensitive race-related issues (Boyd-Franklin, 2003a). In Box 3.4, we

illustrate a culturally sensitive approach to a family of Mexican heritage. What the family

presents as a school truancy problem can be seen in a broader social context as a sociocultural

problem.

Further, in working with acculturational and adaptational issues with immigrant fam­

ilies (Berry, 1997), therapists need to take care to distinguish between recently arrived

immigrant families, immigrant American families (foreign-born parents, American-born

or American-educated children), and immigrant-descendent families (Ho, Rasheed, &

Rasheed, 2004). Each has a specific set of adaptational problems-economic, educational,

cognitive, affective, emotional. Acculturation has been found to involve differences in each

family regarding the mix of continued endorsement of the culture of origin and adoption

of elements of the new host culture; family processes may mediate acculturation effects on

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68 CHAPTER 3

Counseling a Latino Family

The Ortiz family, consisting of Roberto, 47, the father; Margarita, 44, the mother; and two daugh­ ters, Magdalena, 12, and Rosina, 10, had never been to a counselor before, and they arrived to­ gether at the school counseling office for their early evening appointment with little prior under­ standing of what the process entailed. Unaware that they could talk to a counselor at school about child-related problems at home, they were summoned by the school authorities as a result of poor and sporadic school attendance by the chil­ dren during the previous 6 months. Magdalena had actually stopped attending, and her younger sister, Rosina, had recently begun to copy her sister's behavior, although she did go to class some days.

Arranging for the Ortiz family to come to coun­ seling presented several problems. Although Mrs. Ortiz had been in this country for two de­ cades, having arrived from El Salvador by ille­ gally crossing the border at Tijuana, Mexico, with an older brother when she was 25, she spoke English poorly; and she felt self-conscious about her speech in front of the school authorities. Mr. Ortiz, himself an undocumented immigrant from rural Mexico, had been in this country lon­ ger and had taken classes in English soon after arriving. He, too, had to be persuaded that all the family members needed to be present. Both parents had recently been granted amnesty under federal immigration regulations and had looked forward to their children having better lives in the United States. Needless to say, both parents were very upset upon learning their children were school truants.

The school counseling office arranged for Augusto Diaz, one of the counselors, to see the Ortiz family. Of Mexican heritage, Mr. Diaz was a third-generation Latino American who himself had learned Spanish in high school, never hav­ ing heard it spoken at home growing up. He was sensitive to what each of the Ortiz family mem­ bers was feeling and to the proper protocol for reaching this family. He began respectfully by

addressing the father as the head of the house, thanking him for allowing his family to attend but indicating that the children could not be allowed to skip school and that there were legal conse­ quences if they continued to do so. Aware that Mrs. Ortiz seemed to be having trouble following his English, Mr. Diaz enlisted Magdalena as trans­ lator. From time to time, he used Spanish words or idioms when appropriate, although he himself was quite self-conscious about his Americanized Spanish. He, too, turned to Magdalena when un­ certain of whether he had said in Spanish exactly what he had intended.

The first session was essentially designed to familiarize the family with what they could expect from counseling, to build trust in the counselor, and to show them that he was interested in their situation and would try to help. Mr. Diaz encour­ aged all family members to participate and com­ mented several times on the father's strength in bringing his family in to discuss these issues. They arranged another evening appointment for the following week, at a time that would not interfere with Mr. Ortiz's daytime gardening job or Mrs. Ortiz's daytime occupation as a domestic worker.

When Mr. Ortiz finally felt comfortable enough to share his thoughts, he said that girls did not need higher education, that his daughters al­ ready knew how to read and write, and that had he had boys it would have been different. He was upset, however, that they were disobedient and disrespectful in not telling the parents that they were not attending school but lying instead about how they spent their days. Although Mrs. Ortiz seemed to agree, she also revealed that she her­ self was suspicious of the school as well as most of what transpired in her adopted country. She hinted that she knew about the truancy, adding that she was afraid for her children in the mixed Hispanic-African-American neighborhood in which they lived and was just as happy that they stayed home rather than being influenced by their rougher classmates. Mrs. Ortiz saw her daughters'

being home as an opportunity for some help for her after a long day and as good training for their eventual marriages.

Both Magdalena and Rosina, mute unless asked direct questions in the first two sessions, be­ gan to open up in the middle of the third family meeting. They admitted feeling isolated at school, especially because their parents would not allow them to bring classmates home or to visit others after dark. They confessed to being intimidated by gangs, something they had been afraid to reveal to their parents, who, they felt, would not under­ stand. Staying away from school had started as a result of Magdalena's being attacked by an older girl on the school playground, after which the girl warned her to stay away or she would be seriously hurt. Rosina usually followed her older sister's lead and was certain that if her sister was afraid then the danger was real.