CASE STUDIES; A Rose by Any Other Name?: Never Underestimate the Clinical Significance of Culture

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I REMEMBER THREE MISTAKES I MADE AT THE VERY BE-ginning of my work with Rose, a 21-year-old client who came to the clinic because she was having symptoms of insomnia, loss of appetite, failure to concentrate, and inability to cope with her academic load or perform at her part-time job at the library. These three mistakes became a lesson for me about all my work with clients who have come after Rose, helping me to refocus my lens from what I had been taught to consider relevant information about clients. The three mistakes were these: I ignored her ethnicity, our ethnic and cultural differences and the larger social contexts that were directly affecting our lives.

Multiculturalism has been something of a fad in our field, but in my work it is the center and foundation of how I help clients untangle the painful areas of their lives. To me, now, not looking at ethnicity and the social context would be like a psychoanalyst never asking about the patient's mother: it's just not done. So why had I ignored Rose's ethnic and cultural history?

Rose was my first non-Latino client. Until she called to arrange an appointment, my clientele was mainly composed of recent immigrants who were trying to cope with the multiple changes and new complexity of their lives in a foreign environment. Many of these clients were college students from Latin America, young adults who came to see me in their search for strategies to cope with the painful and difficult experiences embedded in their new ethnic-minority status, which were having an impact on their college life. It was through a former client that Rose found out about our agency and decided to call. "I know you have helped some of my classmates," she told me, "and although I am not Latino, I was wondering if you could help me." I immediately thought to myself that it would be good for me to have some exposure to ethnically diverse clients, and agreed to see her.

When I first met her, Rose looked like one of those teenage girls on the cover of a glossy magazine. To me, she looked "white." She was born and raised in the Midwest, spoke unaccented English and was Episcopalian. How much more American can you be? She was upper-middle-class, part of the mainstream of American life, so the idea of exploring her ethnic background or raising themes of her cultural identity or socioeconomic status themes that always arise in my work with Latino and immigrant clients seemed irrelevant. For the first time, I was seeing a client who seemed to fit the models in all my family therapy textbooks. I was like a person who has read a lot about cars but never driven one: I was anxious to take these family therapy models out for a spin. Drawing from systemic and developmental perspectives, I focused the assessment on defining and tracking her symptoms in the context of her family lifecycle. I explored family triangles and levels of differentiation, tracking the overfunctioning and underfunctioning dynamics, their diffused boundaries, the significant feedback loops between sub-systems all the good stuff I figured I needed to come up with my perfect systemic hypothesis.

In our first session, Rose complained about feeling isolated from her peers. She considered herself immature and socially inadequate, and said she felt like an "outsider" who did not "belong" in her new environment. She was also concerned with her diminished interest in school and her eroding ability to concentrate. She thought her parents' marital problems, which had come to the surface a year ago two years after she left home were draining all her energy. Her mother experienced depressive episodes and had begun to drink heavily. Her father, she told me, had a "delayed middle-age crisis," which he acted out through frequent extramarital affairs with younger women. Rose would call her mother almost every day to check on her mood, and would also try to convince her father to stop running around. She thought her calls helped to "distract" them from their problems. …