1: Using the Culturagram and an Intersectional Approach in Practice With Culturally Diverse Families

DOI:

10.1891/9780826154156.0001

Authors

  • Congress, Elaine P.
  • Kung, Winnie W.

Abstract

From the beginning of the profession, social workers have stressed the importance of respect for clients from diverse backgrounds. The most recent Code of Ethics advises social workers to understand cultural differences among clients, to demonstrate competence in working with people from different cultures, and to work against discrimination based on immigration status. This chapter discusses the culturagram, a family assessment instrument that grew out of the recognition that families are becoming increasingly culturally diverse and that social workers must be able to understand cultural differences among and within families. Completing a culturagram for a family can help a clinician develop a better understanding of the sociocultural context of the family, which can shed light on appropriate interventions to take with the family. The chapter examines the ten aspects of the culturagram and provides case vignettes.

INTRODUCTION

The United States is becoming increasingly culturally diverse. It is estimated that by the year 2049 less than half (49.7%) of the population will be non-Hispanic Caucasian (Frey, 2014). While the number of foreign-born people is 13% at the national level, in large metropolitan areas, such as New York City, as many as 37% of its residents are foreign-born (Batalova, Batalova, Blizzard, & Bolter, 2020; New York City Mayor’s Office of Immigrant Affairs, 2018). Additionally, approximately 38% of the U.S. population, aged 5 years and older, speak a language other than English at home, with Spanish being the most common other language (U.S. Census Bureau, 2015). In large urban areas such as New York City, one in every two people speak a language other than English at home (New York City Department of City Planning, 2017).

From the beginning of the profession, social workers have stressed the importance of respect for clients from diverse backgrounds (Addams, 1911). In the most recent Code of Ethics, social workers are advised to understand cultural differences among clients, to demonstrate competence in working with people from different cultures, and to work against discrimination based on immigration status (National Association of Social Workers [NASW], 2018). The culturagram, a family assessment instrument discussed in this chapter as well as in the previous editions of Multicultural Perspectives in Working With Families, grew out of the recognition that families are becoming increasingly culturally diverse and that social workers must be able to understand cultural differences among and within families.

When attempting to understand diverse families, it is important to assess the family within its cultural context. Considering a family only in terms of a generic cultural identity, however, may lead to overgeneralization and stereotyping (Congress, 2008b). A Puerto Rican family that has lived in the United States for 40 years is very different from a Mexican family that emigrated last month, although both families are Hispanic. A Chinese family that emigrated to the United States in the early 20th century is very different from a Tibetan refugee family that has recently been relocated. Even two families from the same country and region can be very different.

Understanding cultural and ethnic differences, however, only provides a partial view of understanding and working with families. An intersectional approach stresses the importance of considering different aspects that contribute to a person’s identity. The current NASW Code of Ethics stresses the importance of adopting an intersectional approach in addition to understanding the effect of culture and ethnicity (NASW, 2018).

Social workers should obtain education about and seek to understand the nature of social diversity and oppression with respect to race, ethnicity, national origin, color, sex, sexual orientation, gender identity or expression, age, marital status, political belief, religion, immigration status, and mental or physical ability. (NASW Code of Ethics 1.05 c)

This is very apparent when providing social work services to people from different cultures and ethnicities. Even within the same ethnic group, there are many other differences that can affect our work; for example, a member of an Asian Indian family that is well educated and from a high socioeconomic status is very different from a member of a poor family. While social workers often work with clients who are of lower socioeconomic background, this is not always the case. To help understand this within-group diversity, an intersectional analysis is helpful and is discussed more in depth and applied to case examples later in the chapter.

THE CULTURAGRAM

While traditional family assessment tools such as the ecomap (Hartman & Laird, 1983) and genogram (McGoldrick, Gerson, & Petry, 2008) are useful tools in assessing the family, they do not address the important role of culture in understanding the family. The culturagram was first developed (Congress, 1994, 1997) and revised (Congress, 2002, 2008b) to help in understanding the role of culture in families. This tool has been used to promote culturally competent practice (Lum, 2010) and in work with battered women (Brownell & Congress, 1998), children (Webb, 1996), the elderly (Brownell, 1997; Brownell & Fenly, 2008), immigrant families (Congress, 2004a), and families with health problems (Congress, 2004b; Congress, 2018). Most recently, the culturagram has been used to work with Indigenous peoples (Congress & Ellington, 2018; Ellington & Roy, 2018), and there has been initial discussion about its possible use with those with late onset of visual disabilities (L. van de Meibel, personal communication, April 29, 2019).

The culturagram, a family assessment tool, serves to individualize culturally diverse families (Congress, 1994, 2002, 2008b). Completing a culturagram on a family can help a clinician develop a better understanding of the sociocultural context of the family, which can shed light on appropriate interventions to take with the family. Revised in 2008, the culturagram examines the following 10 areas (Figure 1.1):

  1. Reasons for relocation

  2. Legal status

  3. Time in the community

  4. Language spoken at home and in the community

  5. Health beliefs and access

  6. Impact of trauma and crisis events

  7. Contact with cultural and religious institutions, holidays and special events, food and clothing

  8. Oppression and discrimination, bias and racism

  9. Values about education and work

  10. Values about family structure—power, hierarchy, rules, subsystems, and boundaries

Figure 1.1
Depiction of a culturagram assessment tool.
9780826154156_fig1_1

Source: Reproduced from Chang-Muy, F., & Congress, E. (Eds.). (2016). Social work with immigrants and refugees: Legal issues, clinical skills, and advocacy (2nd ed., p. 75). New York, NY: Springer Publishing Company.

Reasons for Relocation

Reasons for relocating to the United States vary among families. Many families come because of economic opportunities in the United States, while others relocate because of political and religious discrimination, and social unrest in their countries of origin. For some, it is possible to return home again. They often travel back and forth for holidays and special occasions and may ultimately move back to their countries of origin. Being able to maintain continuous close social ties with families of origin and other acquaintances in their native countries reduces the sense of uprootedness that families experience in migrating. Such close contacts also facilitate families, especially younger members, to maintain their cultural heritage and identity. The cultural gap between the generations in these immigrant families may be diminished as a result. For those who know they can never go home again, the sense of isolation and the need for a greater social network in this new land becomes more poignant. The social worker can encourage them to actively reach out to their ethnic communities. Modern means of communication such as email, WhatsApp, Facebook, and Skype have made it possible for immigrants to maintain contact with relatives who still live in their countries of origin.

In contrast to earlier immigration patterns, current immigrants come as families or parts of families (Lum, 2010). Some exceptions include undocumented immigrants from Fuzhou in southern China (Kwong, 1997), and South Asians from India and Pakistan, who frequently come as single persons. Many want to marry within their ethnic group, and “mail-order brides” are not an uncommon phenomenon (Loiselle-Leonard, 2001). Because immigrant brides have to adjust to new roles within their families and adapt to a different culture and geographic location, their stresses are enormous (Liao, 2006).

In cases where the marriage does not work out, these women may feel trapped in this foreign land with no social support. Some may even have to endure domestic violence since the prospect of making it outside of the home in the United States is so dim and the shame of going back to their home countries so unbearable (Loiselle-Leonard, 2001). They feel trapped because their immigrant procedures have not been completed, and they fear deportation if they leave their husbands. Fortunately, changes in immigration laws allow some battered women without legal status to stay (Violence Against Women Act, 2019). This has brought relief and hope to many oppressed immigrant women. However, depending on the current political wind, this guarantee could become precarious.

A common assumption is that most migrants come to large urban centers like New York, Chicago, or Los Angeles. An increasing number of immigrants, however, relocate to rural and suburban areas. After arrival in the United States some migrants move again, often from a rural to a more urban area, due to dwindling economic opportunities. Internal migration involves additional challenges for migrants who must establish a new social network and adjust to a new location as well.

Legal Status

The legal status of a family may have an effect on both individuals and the family as a whole. In the same family, there may be members who are citizens, those who are “green card holders” with the legal right to remain in the United States and proceed toward citizenship, and those who are undocumented without legal status. Chang-Muy’s chapter “Legal Issues in Practice With Immigrants and Refugees” in this book explains in greater detail different immigrant statuses. If family members are undocumented and fear deportation, the family may become secretive and socially isolated. Latency-age children and adolescents will be discouraged from developing peer relationships because of the fear of others learning about their status. Using the family systems lens, the external boundaries of these families may become more rigid and, within these families, a corresponding trend toward more diffuse internal boundaries leading to greater enmeshment. The family may resist seeking necessary social and health services lest they be deported. There was increased anxiety about this after the World Trade Center attack and even more so in recent years when the immigration issue became a heated political debate with more imminent threat of deportation.

Some undocumented immigrants come to this country on their own, leaving behind their families and support system. An example is the influx of immigrants from Fuzhou, southern China, in the 1990s (Kwong, 1997). These immigrants have experienced enormous hardship, handicapped by the language barrier and the enormous economic burden of having had to repay the smuggling debts to come to this country (Kwong, 2002). Moreover, the lack of medical benefits makes life even harder when they have health or mental health problems (Kwong, 2002). A social worker working with this population in Chinatown in New York City revealed that, perhaps due to social isolation and enormous stress, many individuals suffering from schizophrenia displayed a revolving-door phenomenon, going in and out of hospitals after brief psychiatric treatments. The relapse rate was as frequent as four times a year.

A more recent influx of refugees from Central America has raised enormous concern in the United States. The higher rate of migration is due to the unstable social condition in those countries partly due to economic hardship, and partly from powerful gangs threatening people’s lives and livelihood. Some came without legal documents as refugees and wanted to seek asylum, and some came to join their relatives who are legal residents of the United States. The receptivity in this country and communities could make life easier or harder for these immigrants.

Length of Time in the Community

The length of time living in the community may differ for individual family members. Usually family members who arrived earlier are more assimilated than other members. A recent phenomenon involves mothers from Guatemala or South America first immigrating to the United States and then sending for their children. These circumstances can certainly impact individual and family development. Not only does the disruption of the primary caregiver at a critical period affect the child’s development, the subsequent reunion at an older age in this country could also cause some adjustment problems for the family, which is often manifested as the child’s behavioral problems at school (Patel, Clarke, Eltareb, Macciomei, & Wickham, 2016). Sciarra (1999) suggested that the issues these families face include resentment by the children over the parents’ earlier “abandonment,” the conflict between loyalty toward the reunited parents and the interim caregiver from whom the child is now forced to separate, inadequate parental authority and leadership, and the different level of acculturation between the parent and the child. Sciarra (1999) found that techniques such as reframing the intergenerational conflicts as intercultural issues and stating the treatment goal as working toward biculturalism were helpful.

The problems faced by other immigrant families are the exact opposite of these reunited families. These have been called the “astronaut families” (Irving, Benjamin, & Tsang, 1999). Because of the political instability in Taiwan and Hong Kong in the past couple of decades, many Chinese families migrated to the United States, Canada, and Australia. However, such moves often meant an economic loss to these families since the breadwinner, usually the father, experienced diminished income in his career as his professional qualifications and experiences overseas are often not recognized in the host country. Many families opt to have the children and the mother migrate first, while the father “shuttles” back and forth to join the family periodically. Not only does it pose challenges to the marital relationship, sometimes resulting in affairs and marital breakdown, it also jeopardizes the father–children relationship. These are high prices to pay for migration.

Language

Language is the vital medium through which families communicate. Often families may use their own native language at home, but use English in contact with the outside community. Sometimes children may prefer English as they see knowledge of this language as most helpful for survival in their newly adopted country. This may lead to conflict within the family. A very real communication problem may develop when the parents speak no English and the children only minimally speak their native tongue. Another key factor affecting family communication is that members relocate at different ages. As children attend American schools and develop peer relationships, they often pick up the new language and culture more quickly than their parents. This may lead to shifts in the power structure of the family as the parents’ limited English competency can erode their authority (Hendricks, 2013; Hong, 1989). In some situations, the children may assume the role of interpreter and cultural broker for the family, and sometimes even the leadership role since they have better knowledge about community resources. This may be especially difficult for cultures in which the generational hierarchy within the family is important (Tamura & Lau, 1992).

One of the challenges in the work of bilingual social workers with a bilingual family is that they have to decide which language to adopt and when. Caution should be taken to ensure that the worker does not appear to be “siding” with either the English or the native speaker. For families in which the children can understand but not speak the native language, it is important for the bilingual worker to speak mostly in the native tongue even when talking to the children to indicate that the language is respectable and to show respect to the parents (Hong, 1989). When an interpreter is needed, care must be taken if the worker decides to use a family member as interpreter to ensure that they do not avoid or distort sensitive messages. For example, social workers must ensure that the interpreting family member does not avoid explorations of suicidal ideations when they do not feel comfortable asking the questions and believe that suicide would not happen (Hong, 1989). Discussion with an external interpreter before meeting with the family is also helpful to ensure that the interpreter understands the major thrust of the session (Hadziabdic & Hjelm, 2013).

Health Beliefs and Access

Families from different cultures have varying beliefs about health, disease, and treatment (Congress, 2004b, 2018; Congress & Lyons, 1992). Many medical anthropologists have contended that individuals’ cultural beliefs influence the way they perceive the etiology of an illness, interpret the symptoms, and act on the symptoms (Cheng, 2001; Kleinman, 1980; Tseng, 2001). Individuals’ and families’ health beliefs, which include their perception of their susceptibility, the seriousness of the consequence of an illness, and the benefit of medical intervention, affect their readiness to use preventive health services and to seek actual help when a family member faces an ailment (Hsu & Gallinagh, 2001; Rosenstock, 1990). Families’ reactions to an illness can affect the course, outcome, and level of incapacitation of an illness and the families’ adjustment to it (Lescano, Brown, & Lima, 2009). For example, a delay in seeking treatment for HIV/AIDS because of stigma could lead to more devastating and lasting impact on the family through transmission of the illness to other family members.

There are differences between immigrant and refugee groups in how they understand mental illness (Bemak & Chung, 2000). Among many Asians, mental illness is seen as the result of malingering bad thoughts, lack of willpower, and personality weakness (Kleinman & Hall-Clifford, 2009; Narikiyo & Kameoka, 1992; Suan & Tyler, 1990; Sue & Morishima, 1982). Hence, self-control and solving one’s own problems are culturally valued, and seeking help from mental health professionals is often delayed or avoided (Boey, 1999; Sue, Cheng, Saad, & Chu, 2012; Zhang, Snowden, & Sue, 1998). Given Asian Americans’ tendency to somatize emotional distress, emphasize the physical expression of one’s distressed state (Kleinman, 1980; Kung & Lu, 2008; Yang, Cho, & Kleinman, 2008; Zhang et al., 1998), or subscribe to the holistic mind–body–spirit conceptualization, they are likely to turn to physicians, herbalists, acupuncturists, fortune tellers, or ministers for help instead of mental health professionals (Kung, 2001; Kung & Lu, 2008; Sue, Nakamura, Chung, & Yee-Bradbury, 1994). Some Hispanics may rely on botanicas or spiritualists as the first and sometimes the only attempt to dealing with health or mental health problems (Congress, 2004a). The intense stigma attached to mental illness in some cultures also poses barriers to seeking mental health service (Kung, 2004; Kung & Lu, 2008). Some of these impediments to help seeking among Asians include the attribution of psychiatric problems to hereditary causes, interpreted as “genetic taints” and “bad seeds” (Kung, 2003; Pearson, 1993; Sue & Morishima, 1982). Because of the sociocentric nature of the Asian culture (Triandis, 1989), families are concerned about the loss of face and avoid reaching out for help beyond the immediate family, thus overburdening the family (Kung, 2001; Sue & Morishima, 1982; Sue, Sue, Neville, & Smith, 2020). Hispanics may seek to avoid the label of “loco” because of the stigma connected with this designation (Congress, 2018).

In the face of physical illness, many immigrants prefer to use healthcare methods other than traditional Western/European medical care involving diagnosis, pharmacology, x-rays, and surgery (Congress, 2018). The social worker who wishes to understand families must study their unique healthcare beliefs (Congress, 2013).

Immigrants, especially those who are undocumented, may have limited access to ongoing healthcare (Derose, Escarce, & Lurie, 2007; Goldman, Smith, & Sood, 2006). Denied access to regular healthcare and prevention, many immigrants are forced to rely only on emergency care. The Health Care Reform Act (NILC, April 2010) did not greatly expand healthcare coverage to immigrants as it denied healthcare to undocumented immigrants and limited healthcare even for those immigrants who had legal status to remain in the United States. Some states, however, have chosen to provide Medicaid and Children’s Health Insurance Program (CHIP) benefits to children and pregnant women. Even those who are entitled to receive healthcare could be denied access to needed care due to the lack of bilingual service providers serving the monolingual citizens who are non-English speakers (Kung, 2004).

Crisis Events

Many immigrants have experienced multiple traumas in their homelands, in transit, and in their current situation. Often, these traumas can affect the mental health of immigrants and refugees detrimentally (Pumariega, Rothe, & Pumariega, 2005).

Families can encounter developmental crises as well as “bolts from the blue” crises (Congress & Kung, 2013). Developmental crises may occur when a family moves from one life stage to another. Stages in the life cycle for culturally diverse families may be quite different from those for traditional Caucasian middle-class families. For example, for many culturally diverse families, the “launching children” stage may not occur at all, as single and even married children may continue to live in close proximity to the parents (Pew Research Center, 2016). This may be especially true for Hispanics and Asian American families (Snowden, 2007). If separation is forced, this developmental task might become traumatic.

Families also deal with unexpected events and crises in different ways. During the 9/11 attack on the World Trade Center, people from more than 80 countries of origin died (Lum, 2010). There has also been concern that many victims, especially those who were undocumented, were never acknowledged and their families often were not able to secure the assistance that others received. A family’s reaction to crisis events is often related to its cultural values. The death or injury of the male head of household may be a major crisis for an immigrant family that highly values the role of the father as a provider. While rape is certainly a major crisis for any family, the rape of a teenage girl may be especially traumatic for a family that highly values virginity. Furthermore, corporal punishment which may be a rather common disciplinary approach in some immigrant families may cause them to be accused of child abuse and become involved with child protective agencies and the legal system. A referral to child protective services is perceived as a crisis to many families and especially so for those who interpret court-ordered counseling upon disciplining a child as an outrageous punishment—a crisis that evokes tremendous anger and shame (Waldman, 1999).

Different beliefs about the treatment of physical ailments may result in different approaches to remedy these problems. Some approaches may result in parents being accused of abuse or neglect. For example, methods such as coining or cupping administered by parents to help relieve the child’s bodily pain may leave scars that may be misinterpreted as child abuse (Vitale & Prashad, 2017). Some parents may refuse to have their children take medication or have immunizations because of possible side effects or because of their health beliefs, and as a result, in some states they may be accused of child neglect (Parasidis & Opel, 2017). The consequences of such refusal for vaccination are seen as contributing to the recent measles epidemic in some communities.

Holidays and Special Events, Contact With Cultural and Religious Institutions, Food, and Dress

Each family has particular holidays and special events. Some events mark transitions from one developmental stage to another, for example, a christening, a bar mitzvah, a wedding, or a funeral. It is important for the social worker to learn the cultural significance of these events, as they are indicative of what families see as major transition points in their lives. Some ethnic families have their own high holidays, such as the Lunar New Year, which is often considered as important to many Asian families as Thanksgiving to many native-born Americans, if not more so. It is worth encouraging immigrant families to celebrate their own important holidays to help them uphold their tradition and to strengthen their cultural identity. Special foods may be associated with the celebration of these holidays.

Contact with cultural institutions often provides support to an immigrant family. Family members may use cultural institutions differently. For example, a father may belong to a social club, the mother may attend a church where her native language is spoken, while the adolescent children may refuse to participate in either because they identify more with the American culture. Religious faith may provide much support to culturally diverse families, and the clinician will want to explore their contact with formal religious institutions. Some clansmen’s associations are common among Asian Americans, often providing important support to immigrant families. For example, they provide significant financial support for new Chinese immigrants from Fuzhou in New York City (Kwong, 1997). The support among business owners is also found to be an important factor accounting for the successes among many Korean American businesses (Park, 1997). The social worker should be aware of these resources so as to help families tap into them. Most Asian clansmen’s groups, however, do not provide assistance or support on psychosocial issues due to the lack of knowledge about mental health issues and fear of stigma by many of these immigrant groups.

Oppression and Discrimination, Bias, and Racism

Many immigrants have experienced oppression in their native countries, which has led to their departure from their homelands and immigration to the United States. Some of them enter the United States as refugees because of the extent of social, political, physical, and emotional discrimination and threats they experienced in their countries of origin, while others apply for asylum status after their arrival here because they fear a return to their homelands.

Other immigrants, however, may have been the majority population in their home country and thus never experienced prejudice until their arrival in the United States. In the United States, they may be the victims of discrimination and racism based on linguistic, cultural, and racial differences. The current U.S. policies on undocumented immigrants further serve to separate and discriminate this newcomer population from other Americans. Social workers should be sensitive to the needs of this vulnerable group within their immediate environments, such as bullying of these immigrant groups in school or discrimination in work settings. Support from family members and sympathetic community organizations for these groups should be rallied, and advocacy through consciousness raising can also be part of social workers’ roles to prevent and reduce discrimination and oppression.

After review of previous versions of the culturagram and feedback about the instrument, this area was added in 2008 as an important aspect in understanding the immigrant families’ experience.

Values About Education and Work

All families have differing values about work and education, and culture is an important influence on such values. Social workers must explore what these values are in order to understand the family. Economic and social differences between the country of origin and the United States can affect immigrant families. For example, employment in a low-status position may be very denigrating to the male breadwinner in some cultures. It may be especially traumatic for the immigrant family when the father cannot find work or is engaged in work of a menial nature. This is often a result of the individual’s professional qualifications and experience in their native land not being recognized in this country. Such a downward move in the socioeconomic hierarchy often induces additional stress and challenges for many immigrant families.

Sometimes a conflict in values arises due to competing desires of family members. An example of this occurred when an adolescent child was accepted with a full scholarship to a prestigious university miles away from home. While the family had always believed in the importance of education, the parents believed that the family needed to stay together and did not want to have their only child leave home, even to pursue education.

Another example of such value conflict occurs when latency-age children attend large schools far from their ethnic communities and begin to develop peer relationships apart from their families. For immigrant families that come from backgrounds in which education has been minimal and localized, and where young children were expected to work and care for younger siblings, the American school system with its focus on individual academic achievement and peer relationships may seem alien. Some cultures value education differently for different genders. In the past, many Hispanic girls dropped out of school because academic attainment for girls is not highly valued compared with boys, but this may be changing as more Latinos in general continue in school (Jackson, 2013; Krogstad, 2016). Nonetheless, Latino girls still have major responsibilities in taking care of the household and younger siblings. They often find little or no time left to attend to their academic demands after school and thus have a harder time keeping up with academic work, and may eventually drop out from school.

Furthermore, immigrant children who have experienced a history of individual or family oppression may feel very isolated and lonely in their new academic environments, which is made worse when actual bullying by peers and discrimination by insensitive school personnel take place.

Values About Family Structure—Power, Hierarchy, Rules, Subsystems, and Boundaries

Each family has its unique structure, beliefs about power relationships, rules, boundaries within and outside the family, and significance of certain familial relationships. The clinician should explore the individual family’s characteristics and also needs to understand them in the context of the family’s cultural background. Some families may have particular beliefs about male–female relationships, especially within marriage. Families that promote a male-dominant hierarchical family structure may encounter challenges in American society with its stated preference for more egalitarian gender relationships. This may result in conflict and an increase in domestic violence among minority families (Erez & Globokar, 2009). Traditionally gendered roles within the family also exert significant impact on the family, especially when circumstances change after migration. For example, in some cultures, women are expected to take care of internal familial affairs, including household chores and child care, while men are expected to work outside and be income earners. However, changes in the socioeconomic status of the family after migration may necessitate both spouses to work outside of the home. If the role of domestic caretaker continues to be rigidly assigned only to women, they may become overburdened. In situations in which the woman is able to find a job while the man is unemployed and the family lacks flexibility in their role adaptation, conflict, blame, and burden in the family may become so enormous that it may threaten the survival of the family unit.

Not only is gender hierarchy much affected by cultural norms, so is generational hierarchy. More traditional cultures tend to ascribe much higher authority and respect to the older generation, and in some cultures, parental authority can be rather absolute (Tamura & Lau, 1992). Clinicians should recognize such inherent cultural differences, and sometimes mediate between the generations. They have to navigate cautiously: They should show respect to the family’s culture on the one hand, but tactfully facilitate communication across the generations on the other hand, in order to ease the tension and conflict. Through careful mediation, it is hoped that views from both sides can be heard and considered in the final decision-making. However, sometimes the social worker may have to accept that some cultures do dictate that senior members have the ultimate power in decision-making after the views of the younger generation are articulated, unless it is a violation of the basic human rights of the latter.

Finally, families from different cultures may place varying emphasis on family subsystems. In Western culture, the spousal subsystem is considered the bedrock of the family (Minuchin, 1974). In some cultures, though, the primary unit is the parental subsystem, emphasizing the co-parenting role between the spouses (Connell, 2010). In some cultures, such as the traditional Chinese culture, the parent–child subsystem (both the father–son and mother–son dyads) and even the relationship among brothers are considered more important than the spousal relationship (Tamura & Lau, 1992). Further, the parental subsystem could also be much more inclusive than only the biological parents—for example, not only are grandparents, aunts, and uncles important partners in the parental subsystem, but the godparents’ role could also be very significant in Hispanic families (McGoldrick, Giordano, & Garcia-Preto, 2005). Clinicians should be conscious of cultural values and practices so as not to leave out important system players who could be valuable resources to the family.

Whether the boundary within a family or within a subsystem is considered appropriate or overly diffuse is also very cultural (Connell, 2010). For example, in some Asian cultures, since the future care of the aging mother is dependent on the son, and the mother–son bond is usually close, a mother is often seen as being intrusive in the son’s marital relationship and is sometimes domineering toward the daughter-in-law (Berg & Jaya, 1993). For some Asian families, to have the child to sleep with the parents till the age of 8 or 10 is considered a very normal practice, and it does not necessarily indicate marital dysfunction or enmeshment between parent and child (Berg & Jaya, 1993). Social workers have to avoid judgmental attitudes toward families who have different cultural values from their own.

As stated previously, learning about the cultural norms and values of individuals and families and their unique immigration experiences is only the first step. The clinician also needs to consider other aspects of an individual’s identity such as race, ethnicity, religion, nationality, immigration status, ability/disability, socioeconomic status, health status, education, occupation, and sexual orientation that affect how the individual self identifies. Each person is a member of many communities and many cultures. In this sense, each of us is “multicultural.” It is important to note that these social categories carry with them varying levels of power, or lack thereof. Such dimensions further intersect and overlap with each other, and with the culture and ethnic groups to which individuals belong. For individuals who fall into multiple minority statuses, oppression is further aggregated (Crenshaw, 1989; Dill & Zinn, 1994). To expand our understanding, an intersectional design tool (IDT) was developed and is presented here in Figure 1.2.

Figure 1.2
Intersectional design tool.
9780826154156_fig1_2

Source: Elaine P. Congress (2017).

In the two case vignettes that follow both the culturagram and the IDT will be used to promote greater understanding of clients and families from diverse backgrounds.

CASE VIGNETTES

Mrs. Maria Sanchez, 32 years old, contacted a family service agency in her community because she was having increasing conflicts with her 12-year-old son, José, who had begun to cut school and stay out late at night. She also reported that she had a 9-year-old daughter, Maritza, who was “an angel.” Maritza was very quiet, never wanted to socialize with other children, and instead preferred to stay at home with her mother helping her with household chores. Maria indicated the source of much conflict was that José believed he did not have to respect Manuel, Maria’s current partner, as the latter was not his real father. José complained that his mother and stepfather were “dumb” because they did not speak English. José felt it was very important to learn English as soon as possible since several students at school had made fun of his accent. He felt that his parents did not understand how difficult his school experience was as he believed that teachers favored lighter-skinned Latinos. José had much darker skin than his mother, his mother’s partner, or his half-sister Maritza. The recent holidays had been especially difficult as José had disappeared during the New Year’s weekend. Mrs. Sanchez was Catholic but did not go to church because she could not understand in the masses which were in English.

At 20, Maria had moved to the United States from Puerto Rico with her first husband José Sr. The two were very poor in Puerto Rico and had heard there were better job opportunities here. When José Jr. was an infant, José Sr. had made a visit back to Puerto Rico and never returned. Shortly afterward, Maria met Manuel, who had come to New York from Guatemala. After she became pregnant with Maritza, they began to live together. Manuel indicated that he was very fearful of returning to Guatemala, as several people in his village had been killed in political conflicts. Because Manuel was undocumented, he had been able to find only occasional day work. He was embarrassed that Maria had been forced to apply for the government’s Supplemental Nutritional Assistance Program (SNAP). Maria received minimum wages as a home care worker. She was very close to her mother, Gladys, who had come to live with the family 9 years ago. Gladys had urged Maria to seek help from a spiritualist to help her with her family problems before she went to the neighborhood social work agency to ask for help. Manuel has no relatives in New York City, but he has several friends at the social club in his neighborhood.

Not only does the culturagram and IDT facilitate the social worker in assessing families from different cultural backgrounds, they also give directions for appropriate interventions. After completing the culturagram (see Figure 1.1) and IDT (see Figure 1.2), the social worker was better able to understand the Sanchez family, assess their needs, and begin to plan for treatment (see Figure 1.3). She noted that Manuel’s undocumented status was a source of continual stress in this family. She referred Manuel to a free legal service that provided help for undocumented persons to secure legal status. She also explored their religious affiliation and found that although the family subscribed to the Catholic faith, they had not attended church since they came to this country, because they could not find a church with Spanish-speaking masses. The worker helped the family find a Catholic church in the neighborhood that has a weekly mass in Spanish and a large proportion of Hispanic parishioners. The church later became a support network for the family as Maria and Maritza became involved with the women’s and children’s groups at the church.

The social worker recognized some kind of communication problem across the generations. While José and Maritza are bilingual, they often speak English at home, which for the most part Maria and Manuel do not understand. The adults communicated with each other and the children in Spanish. Maria and Manuel sometimes wanted to practice their English with the children, but the latter, especially José, were rather impatient with their parents’ broken English. In any case, communication was limited to basic information exchange and rule setting. The social worker encouraged the couple to study English in a free English as a secondary language (ESL) adult education program in their neighborhood. The bilingual worker, however, was careful to speak in Spanish when seeing the couple and especially during family sessions so as to subtly convey respect for the language to the children. When she had individual sessions with the children, she used English since they were better able to express themselves.

Figure 1.3
Culturagram and IDT applied to the Sanchez’s case example.
9780826154156_fig1_3

Note: The previous version of the culturagram appeared in Congress (2008a) and the IDT was first presented at CSWE APM (2017).

Due to language barriers, José occasionally had to act as interpreter on behalf of the family, for instance, when the family had to deal with the Social Security department or with his grandmother’s medical doctors during a serious illness that involved hospitalization. José was sometimes resentful toward these familial obligations as it took away time from being with his peers. He also felt that all his mother and stepfather wanted was to ask him to help out in the family and to impose rules on him without ever caring about his needs. The worker reframed his responsibility for the family as having an honorable task as cultural broker, but recognized his need for appropriate autonomy. While the worker worked toward the therapeutic goal of empowering the parents, especially the mother, to assert control over José, she also acted as a mediator to help the parents understand José’s need to gain more age-appropriate independence.

Within the school, José reported that he had often been the subject of bias and discrimination. The clinician working with this family might want to contact the school to learn more about their policies and programs in helping students from different cultural backgrounds.

Maritza’s social withdrawal was also explored. It was found that Maritza wanted to stay home to do the household chores as this was expected of her as a girl. She noted that her family did not think it appropriate that men in the family (her father Manuel and her brother José) help out with household chores. She wished to spare her mother from additional chores after a hard day’s work outside, and to lighten her grandmother’s load because of her frail health. As a result, she sacrificed her playtime with peers and stayed home to take care of the house. The social worker tactfully invited Manuel to be more involved in domestic duties on days that he did not have to work and reframed it as his way of showing his love for the family through such sacrifice. Maritza was also encouraged to attend activities at the church and after-school programs so as to socialize more with her peers.

Being a racial minority, coming from lower socioeconomic background and being immigrants to the United States, Maria’s family is in a position of having very little power, and even experiences oppression (e.g., José being bullied by his peers). In addition to the social worker’s role of providing counseling in promoting better understanding and communication within the family, and helping each member to meet their own needs, it was important to help them to navigate around the systems in order to gain access to needed resources. For this family, it included assistance to Manuel in applying for legal status, locating free adult ESL classes for Maria and Manuel, and finding a Spanish-speaking church for the family.

The following is another case vignette about an immigrant family.

Ping is a 44-year-old Chinese woman who was referred for counseling at a family service center in Chinatown by the psychiatrist who was treating her husband for his mental illness. At the intake interview, she revealed to the social worker that she suffered from nervousness, frequent palpitations of the heart, difficulty breathing, and insomnia as she was faced with her husband’s frequent temper tantrums. She often felt “caught in the middle” in her relationships with her in-laws over the care of her husband and her two children aged 18 and 16.

Ping came from a poor rural area in southern China. She immigrated to the United States 20 years ago as part of an arranged marriage to a man whose family had successfully immigrated to this country. The marriage was an explicit arrangement in which the groom’s family found a wife for a son with mental health issues, and the bride’s family could gain American citizenship. The client’s motive for marrying was a filial willingness to better her family’s prospects.

The client worked in restaurants in Chinatown when she first came to the United States but eventually became fully preoccupied with the care of her husband and their two children. The husband has been diagnosed with schizophrenia, and three years ago contracted HIV through prostitutes. The couple has not been sleeping together for over 10 years, and the client did not react strongly to this. It was when the husband began a regimen of anti-viral drug treatment for his HIV that his mental health seriously deteriorated. The erratic and paranoid behavior that followed affected the son who became prone to violent outbursts. Neither the husband nor the son admitted to any mental health or emotional problems, and the extended family was opposed to the client’s efforts to seek help outside of the traditional and familial channels. Ping persisted, however, and eventually was able to gain access to a range of services including psychiatric care for her husband, and counseling help for herself. The family was very poor as Ping and her children receive public assistance and her husband Supplemental Security Income (SSI). Since the amount of public assistance she received was very low, she occasionally supplemented her income by day work in a Chinese restaurant where she knew the owner.

By the time the client arrived at the agency, there had been an amelioration of her husband’s symptoms, though caring for him still left her drained. The young daughter lived separately with her paternal grandparents and had been doing reasonably well. The client’s major concern from the outset was the fear that her son would “get into trouble with the police.” Because of his developmental disability, the son was receiving vocational training with other individuals with mental or physical disabilities, whom he found threatening. Ping feared that he would succumb to bad influences if she could not find him a suitable employment. He also did some “volunteer work” in a small grocery store owned by one of Ping’s friends and had been active in a martial arts group. Over the course of several sessions, it gradually became clear to the social worker that the client sometimes threatened to withhold affection from her son, then left the apartment and stayed with her in-laws and her daughter. This was her way of obtaining compliance and good behavior from the son. The son, in response, however, became more insistent and even violent in an effort to secure his mother’s attention.

Another major issue was that Ping is so preoccupied with her care-giving roles that she rarely thought about her own needs and self-care. It was, however, also a reality that she played a very vital role in her family, which was sustained by the social and cultural presuppositions of her marriage. One of the few areas where the client found time for herself was in her life of faith. She was a Buddhist and spent several hours in the temple each Sunday, where some kind of small group sharing and support was often available. The client’s cultural understanding of “help-seeking” seemed to have caused her to look up to the helping professionals as the experts, thereby relinquishing her own initiative and input in the counseling process. Due to the fragmentation of services, the need to respond to many agencies on behalf of her family was itself a significant stressor for Ping, especially with her limited English proficiency.

Using the culturagram and IDT, the worker was able to gain a more comprehensive understanding of Ping and her family’s situation. First, through exploration of the reason for relocation, it was clear that at the outset the client agreed to enter into a very difficult situation with an arranged marriage to a person with mental illness. Her obligation to stay in the marriage to facilitate her family of origin to migrate to the United States could be a pressure in addition to the usual migration stress experienced by new immigrants. The worker came to an appreciation of the importance of the cultural value of filial piety to the client and her obligation to her family of origin as well as her family of procreation. The worker understood and respected the centrality of family in the Chinese culture. However, the worker was able to help the client to strike a balance in taking care of herself and her family by highlighting the fact that if she were not in a state of well-being, she was in no shape to perform her familial roles adequately. In this reframing, the worker started where the client was, fully accepting her cultural obligation to her family.

Although Ping had migrated to the United States two decades ago, because of her language barrier her contact and support in the community were very limited. The worker took note of the client’s Buddhist faith and the support she obtained from it spiritually and through social support at the temple. The client was encouraged to maintain regular visits there. Due to the limited social support the client had, the worker also referred her to a support group at the counseling agency for relatives of patients with a mental illness. The worker also encouraged Ping to enroll in ESL adult classes to improve her English so as to increase her mobility in the city beyond the Chinese community. It should be noted here that many entitlement agencies, health, mental health, and social services are in extreme shortage of bilingual staff to provide services to minorities with limited or no English proficiency. This is indeed discrimination. Various agencies and organizations were involved with the family, including Social Security, Medicaid and mental healthcare for her husband, vocational training and counseling for her son, individual and group counseling for the client, and an Asian community center with adult education programs of ESL for the client. The worker had to do a lot of advocacy and case management functions on behalf of the client and her family in order to attain the needed services. Ping’s family’s situation was similar to that of Maria in that, given the family’s racial minority status, lower socioeconomic background, immigrant status, and the disability of Ping’s husband and son, the family had little power to obtain adequate resources to sustain their well-being. Thus, the social worker’s assistance to navigate the systems and to advocate on their behalf to attain needed services could not be overstated.

In the helping process, the worker also realized the deferential stance that Ping often took in relating to him. From an empowerment and strengths-based approach he emphasized the fact that the client knew herself and her family best and thus elicited her input in the counseling process. Conscientious effort was made by the worker to formulate the treatment goals together with Ping throughout. She gradually responded and became more active in the helping process. The client was indeed a very strong and resilient person; her strengths were often reflected back to her by the worker.

As Ping indicated, her family had a lot of resistance in seeking external help for her husband’s mental health and health problems. Delayed help-seeking especially for mental health issues is a rather common phenomenon among Asian Americans since problems are expected to be resolved within the family. The reluctance is partly due to the strong stigma attached to mental illness in many Asian cultures. It was fortunate that the client persisted in her effort to seek external help and eventually was hooked up with various services through the help of the worker. The worker complimented the client’s willingness to seek help, and assured her that sharing difficulties with the worker (“an outsider”) about her family was an active and positive way to help herself and her family instead of a betrayal to her family. Continual family psychoeducation about the nature of mental illness and its course was necessary to help the family to stay in treatment and ameliorate the shame and stigma attached to mental illness.

It is important to note that within the Chinese culture, the parenting role is given greater importance compared to the spousal role. Hence, when Ping chose to focus her concern on her children instead of her husband, it was important that the worker went along with it. Also, the extended family was of great importance in the Chinese culture, and given the circumstance, the client did not want to alienate this source of support. The worker suggested to the client some strategic ways to interact with the son so as to reduce the negative vicious cycle of mutual escalation. He also helped the client to ameliorate the frequent conflicts with her in-laws.

In the Chinese culture, work is given very high value (Yang et al., 2014). Thus, to be able to find some kind of job for Ping’s son is important to her and her family. The worker also noted the informal resources the client was able to rally for the son to engage him in productive activities. The volunteer opportunity at the local grocery store and the martial arts group are important resources available in the Chinese community from which the son can benefit.

The preceding discussions help to clarify how the culturagram and IDT can be used not only to assess the family, but also to help plan pertinent interventions. The culturagram has been seen as an essential tool in helping social workers provide more effective services with families from many different cultures. It enables the practitioner to gain a more longitudinal understanding of immigrant families. As Drachman (1992) stresses, in working with immigrants, it is important to understand not only their current situation but also what they experienced in their homelands and in transit. The culturagram helps the worker to understand the multiple physical and emotional traumas immigrants may have encountered in their countries of origin, their transit to the United States, and in their current environment and thus plan appropriate interventions. The introduction of an intersectional perspective also helps the social worker to understand the multiple groupings that an individual or a family may belong to and how such groups, when they intersect, may affect clients’ self-identity and power within the social structure, and what may be necessary to ensure that they have adequate resources to attain and sustain their well-being.

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