Counseling Across Cultures Case Studies

Counseling Across Cultures. Pedersen. SAGE Publications. 

Case Study of Donna Little - Chapter 5  

Donna Little is a 39-year-old Indian woman who has a history of substance misuse and has struggled with reunification with her adolescent children over the last 6 years. She was in residential school from the age of 6 to 16 years old. She has a history of domestic violence in her previous relationships. Donna was the youngest of four children in her family. Her parents, siblings, and herself were raised in the same small northern reservation. Both her parents had gone to residential school in the early 1950s, as did her grandfathers and grandmothers on both sides of her family system in the late 1910s. Donna was raised in an environment of violence and mayhem in her early childhood, which she has talked about quite extensively in counseling. Although her parents abused alcohol, she emphasizes repeatedly that her family was quite ceremonial and participated in the big drum feast and singing within the community. When Donna was 6, an Indian agent wearing a red, white, and black checkered jacket gave her candy and took her to the residential school. She never had the opportunity to say good-bye to her mom and dad, who died of tuberculosis while she was in the residential school. Donna reflects on her residential school experience with a despondent look. While in the residential school, she had only one friend she could count on. Her siblings, who were also at the school, were older and thus not allowed to play with her or sleep near her at the residence dorms. This created an incredible loneliness that Donna did not know how to fill, and often she would use alcohol to help numb that pain. She did not like to drink, but it helped her to stop her thinking badly about the past. Donna was a victim of sexual abuse in the residential school, primarily by the Roman Catholic priest who was in charge. The first time she was assaulted she was 7; the last assault occurred right before she ran away at age 16. When Donna had attempted to tell the head nun in charge of her dorm what was happening to her, she was beaten severely, to the point of unconsciousness. Donna recalls it was her friend, Sue, who nursed her back to health. Donna describes her life as difficult. She went home to her community, only to find a partner who turned out to be as violent toward her as her father was to her mother. She loves her children and cares for them deeply. She breast-fed her three children and still today can feel that connection to them. When her children were taken from her home after the last time her husband beat her, she spiraled out of control. Donna has had long periods of abstinence, has a home in her community that is well cared for, and now has a partner who loves her deeply. Donna is on welfare but hunts and fishes to help with sustenance. Donna and her partner have been together for 10 years, however, they both misuse alcohol on occasion. Donna’s present partner is nonviolent and a former residential school survivor as well.

1. What is the culturally relevant history a therapist needs to understand when working with a client such as Donna?  
2. What are some of the culturally relevant techniques a therapist can use when working with Native-American clients who have been abused by people in positions of power?   

1. How might Donna’s therapist help her to reconnect with her family in a manner that promotes wellness for everyone?

Case Study of Simon Ho – Chapter 6

Simon Ho is a 19-year-old Chinese American sophomore attending a midwestern university. He has a good academic record, with a 3.25 grade point average, but he is having difficulty understanding various concepts in his advanced chemistry class. With a big exam approaching, Simon is not only increasingly worried but also experiencing headaches and stomach troubles. Fearing the possibility of failing the exam and disappointing his family, Simon decides to seek assistance from his chemistry professor. Upon approaching the professor, he is greeted happily and courteously. His professor spends more than an hour with him, reviewing some of the material for the exam. After this review, Simon feels a bit more confident about his understanding of the concepts. Unfortunately, Simon receives a D on the exam. Disappointed by his poor performance, he begins to skip class to avoid his professor and never seeks his professor’s assistance again.

1. Why does Simon not ask his professor for further assistance or guidance?  
2. How might Simon’s cultural context help to explain his headaches and stomach troubles?  
3. What other cultural factors could also account for Simon’s experience?

Case Study of Liliana – Chapter 8

Liliana, who is 24 years old, is voluntarily seeking counseling for “relationship issues.” She has lived in California’s San Francisco Bay Area for most of the time since her family emigrated with undocumented status from Mexico. Recently married, Liliana currently lives within a few miles of her mother and sisters. Liliana’s family of origin is economically poor. She has met but does not have ongoing contact with her biological father, who is “somewhere in Mexico.” Her mother and two older sisters are deeply committed to the Apostolic Christian Church, but Liliana does not attend services regularly. Liliana speaks reverently of her grandmother, although relations between the two were tense for a time. Liliana and her grandmother were not speaking to each other because of her grandmother’s rejection of Liliana’s younger sister. According to Liliana, her grandmother could not accept that her sister’s biological father was African American. Despite a very difficult time in public school, Liliana was able to succeed at a small private high school, and she was accepted by an Ivy League university. She left the university after her sophomore year to raise her own family. She is currently working for a successful technology firm as she completes her degree. Liliana’s sense of humor engages young people and adults, her penetrating insights guide conversations, and she is well liked by those who know her well. She continues to defy authority when she feels that it is unjustifiably imposed, is occasionally impatient with what she perceives to be the irrelevance of other people’s emotions or reasoning, and sometimes balks at what she sees as unnecessary or unimportant work. How might the framework described in this chapter be useful to a counselor’s efforts to improve Liliana’s mental health? The framework does not provide a script that Liliana’s counselor might follow. In fact, the framework is designed to discourage a search for solutions, pointing instead to better questions to guide a counselor’s practice. Some of these guiding questions might become actual questions that the counselor could ask Liliana. Others could guide the counselor’s attention during their meetings, helping the counselor discern those important ecological factors, identify the particulars of Liliana’s orientation to the counseling situation, and design and cocreate a safe physical and social space. The discussion questions that follow provide a limited example of guiding questions, organized according to the broad categories of variables described in our framework.

1. What sorts of experiences, if any, has Liliana had with racism and other kinds of discrimination? How have these contributed to the way Liliana sees herself and her lived world? How do race, language, class, gender, and so on matter to Liliana’s beliefs?  
2. How, if at all, does the ethnic, racial, linguistic, or economic background of the counselor matter to Liliana’s orientation to the counseling situation?  
3. Given what the counselor is learning about Liliana’s environment and orientation, what roles might the counselor take on to best meet Liliana’s needs? And under what conditions might such roles usefully vary?

Case Study of Sawsan – Chapter 9

Sawsan, a 17-year-old girl, was brought by her father to counseling because she had withdrawn herself from family meetings and activities during the past 2 months, instead spending most of her time listening to music in her bedroom. Lately, she had complained about headaches that lasted all day with no relief, despite the use of painkillers. The family’s medical doctor had told Sawsan’s parents that she may be passing through a stressful period and referred them to counseling. At the initial intake meeting with Sawsan and her father, the father dominated the conversation, and Sawsan displayed approval of his views. The father described her as a perfect girl who always met her parents’ expectations in school and in social behavior. The change in her behavior made her seem to him as “not her.” He tried to attribute this change to “bad friends” or “bad readings.” He also denied that Sawsan was experiencing any stress and emphasized how much the family loves Sawsan and cares for her needs. He said, “Nothing is missing in her life. We’ve bought her everything she wants. She couldn’t be passing through any stress.” Knowing that most Arab girls find it very difficult to express their feelings in front of their fathers (or both parents), after listening to the father the counselor asked to be allowed to have a private conversation with Sawsan, and the father agreed. At the beginning of this conversation, Sawsan continued to go along with her father’s views, describing how much her parents love and support her and denying any stress. Only after the counselor validated to her that she indeed has good parents was she ready to reveal a conflict that had been raised recently concerning her desire to study at a university located far from her village, which would necessitate her living in the student dorms. Her father rejected the idea of his daughter living away from the house, far away from his immediate control. In an attempt to compensate for this, he bought her a new computer and suggested that she study at a nearby college. She insisted that she wanted to study at the university and tried to push until her father became angry, claiming that she was imitating “bad girls” who sleep away from their homes. As she described this conflict, she continued to remove any accusation from her father, saying, “He did this because he is worried about my future,” and “He is right and I should understand this.” The counseling process lasted for five sessions, during which the counselor met with only the father three times in order to establish a positive “joining” with his position and worries. The counselor then revealed to the father some contradictions within his belief system regarding the importance of education, as described in culturanalysis. After that, the counselor met with both father and daughter and encouraged Sawsan to explain to her father why she felt she needed to study at the university and to express her commitment to her family values. The counselor also encouraged the father to express his care and worry to Sawsan and then to discuss a compromise that may be accepted by both of them. He agreed to allow his daughter to study at another university, in a city where she could live with her uncle’s family. In a follow-up meeting, Sawsan and her father expressed satisfaction. Sawsan had returned to normal interaction with the family and no longer complained of headaches.

1. Arab Muslim parents tend to attribute bad behavior to external entities such as “bad friends” or “bad readings” or, in some cases, bad spirits. Discuss why or why not this is this something that the counselor may want to address with the parents?  
2. It is often difficult for Arab children to criticize their parents in conversations with foreigners, such as Western counselors, and they typically feel the need to emphasize that the intentions of their parents are good. How should the counselor approach discussing the client’s parents with the client?  
3. Therapy with Arab and Muslim families should not seek to change or confront the family culture or the family structure; rather, it should be aimed at finding better solutions within the fabric of that culture. Explain how the counselor might use a family’s internal resources and strengths to change this situation for the better.

Case Study of Nikki – Chapter 10  Nikki is a 17-year-old male-to-female transgender client. She was sent to counseling by her parents because of their concern that she has become more withdrawn in the past few months. They noticed that she spends much of her time alone in her room and sometimes does not go to school. They are fearful that she will not be able to graduate and go on to college. Nikki disclosed to the counselor that she began to be bullied by her classmates after she asked a friend to the Sadie Hawkins dance. Since then, her classmates have shunned her and she has not felt safe going to school. She mentioned that she would prefer to be homeschooled or to drop out of school. During the course of therapy, the counselor spent time validating Nikki’s experiences, providing psychoeducation to her parents about the effects of bullying, and advocating with school administrators to provide a safe learning environment for her. Nikki eventually was allowed to pursue independent studies while taking select classes with supportive educators who were able to provide her a safe space on campus so that she could work steadily toward graduating with honors.

1. How might you create space for Nikki to explore her gender identity and expressions?  
2. Given your experiences of power, privilege and oppression, what types of countertransference might you have when working with Nikki?  
3. How might you better incorporate issues of gender and privilege in your counseling work with Nikki?

   Case Study of Sean – Chapter 11  Sean, a 15-year-old multiracial (Native American, White, and Black) male, initiated services of his own accord to manage symptoms of depression, including suicidal ideation. Sean was academically advanced for his age and excelled as an artist and skateboarder. He prided himself most on his academic success, and he aimed to graduate from high school early and attend college. Sean had poor self-esteem and lacked a strong cultural identity. In the state where Sean resided, he could consent to treatment. He did so, stating that his father, who was his legal guardian, would not consent. The counselor developed a strong rapport with Sean. Sean was raised in a single-parent household. Sean’s father had a severe and chronic mental illness for which he received sporadic treatment, and he was currently stable. According to Sean, during his childhood he was placed in state custody for a year due to his father’s alcoholism and physical abuse toward him. Sean also spent a year living in a homeless shelter with his father. During this time, he was required to attend therapy, which he found unhelpful to his family. Sean’s father believed it was yet another example of the “White man trying to destroy the Indian.” Sean’s siblings were all incarcerated. His grandparents experienced relocation, boarding school abuse, and slavery. Sean’s immediate family was relatively isolated because of his father’s outrageous behavior. Sean reported that his father would often denigrate him. One day, Sean was limping when he arrived for a therapy session. When asked what had happened, he stated that his father had been angry with him for not doing well in his Native language class and had taken a belt to his legs and then shoved him through the screen door, breaking it. Sean further reported that his father’s fits of rage were a rare occurrence (every few months) and Sean had learned to manage them by accepting the abuse. The counselor reminded Sean of his duty to report child abuse or neglect. Sean then attempted to downplay the story, reporting that he had fallen through the door himself. Sean asked that the counselor not report the incident because he feared being taken away from his father again; Sean felt that his father depended on his care. He was also concerned that any type of investigation would disrupt his schooling and cause his grades to suffer. The counselor was conflicted about whether to report. He considered the following points: (a) client safety, including assessment of the severity, frequency, and impact of the abuse and the vulnerability of the client; (b) obligation to report given the state laws around child abuse and neglect; (c) psychological benefit versus harm to the client as a consequence of reporting, including betraying the client’s trust, potential family fragmentation, and loss of stability, predictability, and family social supports in the client’s environment; (d) client level of independence and maturity; and (e) concern regarding the client, family, and community perceptions of social services as a systemic enactment of violence on families. Sean’s family had experienced generations of marginalization and victimization enacted through systems meant to uphold social policies. The counselor consulted with several colleagues. In addition to emphasizing the legal and ethical obligations of the profession, one colleague asked, “What if something more violent or lethal were to happen to this child and you did not report? Would you be able to live with that?” The counselor decided that he could not. He talked with Sean about the need to report, encouraging Sean to report with him, but ultimately the counselor made the call. The counselor had plans to work closely with the family if the case was investigated, to ensure that the caseworker considered the family’s context and culture. He also hoped to help the adolescent develop a safety plan and build broader networks of social and cultural support while also continuing to support him in his academic strengths. However, after the counselor reported the abuse, Sean did not return to counseling.

1. What are the different contexts of marginalization that may have been at play in this situation? How might your experiences of marginalization influence your perspective and choice to report?  
2. How well did the therapist behave in accordance with: (a) the legal standards, (b) the ethical standards of conduct in psychology, (c) the ethical standards of conduct with racial/ethnic minorities and marginalized groups, and (d) personal ethics? Where do the standards conflict or align in regard to this case?  
3. How do you think the therapist’s choice to report affected the client’s marginalization and other issues for which he sought help in counseling? How do you think the client might have been affected if the counselor had not reported?

Case Study of Ling and Mohammed – Chapter 12  

1. Given the information on Ling provided in this chapter, as Ling’s therapist, how would you attempt to strengthen the working alliance by helping her to surface some of her “culture teachers” (Pedersen et al., 2008) and their influences on her decisions and experiences?  
2. Given the information on Mohammed provided in this chapter, what hypotheses do you make regarding his reluctance to focus on his home country? What do these hypotheses imply about the similarities or differences between your worldview and Mohammed’s?  
3. What ethical responsibilities do counselors have for addressing racism and other forms of oppression directed toward international students?

Case Study of Eduardo – Chapter 13  Laura is a counselor at a small, private, progressive, and predominantly White university in the northeastern United States. Laura is a White, straight, U.S.-born cisgender woman of Dutch descent who graduated from an Ivy League university. She has been a mental health practitioner for the past 8 years and considers herself to be an effective and competent clinician. For the past 2 months, Laura has been working with Eduardo, a 19-year-old cisgender man, a freshman at the university, who initially presented with a depressed mood, inability to concentrate, and general anhedonia. Eduardo is an immigrant from the Dominican Republic; he was 5 years old when he arrived in the United States with his family. He grew up in the Southeast, which he considers home and where his family still lives. He is the eldest of four siblings (María, Carmen, and Lissette are 14, 12, and 6, respectively) and the first one in his family to go to college. Eduardo’s parents, who are extremely proud of their “college boy,” worked multiple jobs while he was growing up and now own a small neighborhood restaurant. Eduardo works there during school breaks and is studying business so that he can take over the management of the restaurant and allow his parents to retire. In the course of treatment, Eduardo discloses that for the past 6 months he has been having erotic encounters with men. He discounts these encounters as “just playing” and, after a recollection of every encounter, he tells Laura about his plans to get married to a woman and to have a large family. He tells Laura that he is not gay, because he is “very masculine” (un tigre) and always the “top” during sex, which he considers comparable to having sex with a woman. Lately, Eduardo has been talking a lot about one particular young man, Clive, with a lot of tenderness and affection. Eduardo talks about Clive wanting to go on “real dates” and finds these requests “ridiculous,” as he does not date men. At the same time, Laura notes Eduardo’s worsening mood and apathy turning into passive suicidal ideation. She is familiar with research linking closeted homosexuality with negative psychological consequences. Since coming out is empirically correlated with improved mental and general health functioning, Laura is convinced that Eduardo’s worsening mental health is related to his inability to come out and decides that she will assist Eduardo with this process. Laura’s therapeutic goals are not easy to implement, however. No matter how gently she brings it up, Eduardo becomes angry and, at times, leaves sessions prematurely. At one point, Laura shares her experience of being the only nonlegacy student among her friends at her Ivy League university in order to show Eduardo that she knows what it means to feel different and not always accepted. She also shares the story of her gay cousin, who came out about 10 years ago. She states that she knows how hard it is to come out, but she imagines that things must be so much easier for gay people now than they were for her cousin. Laura’s disclosure is met with a blank stare from Eduardo. One day, Laura looks around her office and notices that none of the books or pamphlets she has available relate to “gay issues.” She makes an effort and brings in pamphlets advertising the university’s Gay, Lesbian, Bisexual, and Queer Student Union. At Eduardo’s next session, she asks him if he would be willing to go with her to the organization’s open house the next week. Eduardo’s eyes well up with tears. He says, “I cannot believe you. You have no idea who I really am.” He storms out of the room and does not come back for his next three scheduled appointments.

1. What assumptions does Laura appear to be making about the etiology of Eduardo’s symptoms?  
2. What are some of the important intersectional issues (in terms of gender, sexuality, and ethnocultural background) at play for Eduardo? What are some of the important intersectional issues at play for Laura?  
3. What sexual orientation microaggressions can you identify in Laura’s interactions with Eduardo?