On Cultural Competence: A Latino Family in American Therapy

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By Alejandra Lindstrom Peralta

To begin, I have only once in my life watched someone dying. I was eighteen when I watched the dying, and it was my sister that was doing the dying.

December 18, 2008

Living at home was not going so well. Between the rage blackouts, [1] the excessive and superfluous clothing purchases, and the un-prescribed Lexapro I had found in the medicine cabinet, it was clear that my mother wasn’t doing too well. And rather than saying anything or taking action, my father stayed longer hours at work during the week and went into the office most weekends, so it was clear that my father wasn’t doing too well, either. None of us were doing too well, but my sister wanted us to know that out of the four of us, she was doing the least well. So, she swallowed half a bottle of Tylenol PM, slit her wrists and said goodbye to us in her own way. “Goodbye ladies + gentlemen,” she wrote in her own blood on the hardwood floor, but only a few minutes later I came home and found her and this whole final performance on earth. Much to her chagrin, I made the executive decision against this being her final performance and got her to a hospital, where over the course of the customary seventy-two hours given to a suicidal patient, they stopped her bleeding, pumped her stomach, and in a sense, brought my dying sister back into the living world.

December 20, 2008

In the seventy-two hours at the hospital, my father and I thought we had finally taken care of the worst of this whole “not doing too well” situation. Much to our chagrin, my mother and, more importantly, her rage blackouts, made the executive decision to come to the hospital, even though my father had expressly forbidden it. (I assume it’s clear to see how interactions between a suicidal teenager and a woman with rage blackouts should be expressly forbade.) My mother stormed past two nurses, my father, and me, and went straight into my sister’s room. “HOW COULD YOU DO THIS TO ME?” she demanded to know from my sister. “WHAT WERE YOU THINKING IN DOING THIS TO ME? HUH? Don’t think you’ve done yourself or anyone any favors. You’ve only made everything worse.” Two nurses and a security guard escorted my mother off hospital premises.

 April 2009

My sister and I did not see my mother for five months after our hospital encounter, except in the setting of intense therapy that we as a family attended many days a week in the subsequent months after my sister’s close encounter with death.

Apparently in therapy we were supposed to consider where we had broken down as individuals, and how that had contributed to our becoming broken down as a family. Some things we considered are, but do not exclude:

1) My mother’s stresses working as a high-powered partner at the largest international law firm in the world translated into a quick temper at home.

2) My sister had just turned fourteen and, as many fourteen-year-olds do, had just entered the throes of teen angst.

3) My father was working as a city attorney in a time when the city was teetering on the edge of bankruptcy, and, in order to keep his job, had no choice but to work as many hours as were demanded of him.

4) I was in my last months of living with my family, college-bound for a place thousands of miles away from home, and had already begun to check out and spend my days dreaming of a place where things might actually start going well.

Some things we did not consider are, but do not exclude:

1) We are all of full Mexican ancestry, and therefore, according to the Diagnostic and Statistical Manual of Mental Disorders, must have our mental health treated with something called “cultural competence.” [2] Mexican families typically live by a cultural philosophy called familismo, which refers to the emphasis on family-level communication and decision-making. [3] It is a mentality in which you do everything “for the group.” An individual’s personal preferences have no consequence if they impede a family from reaching some sort of group goal. This goal, in relation to mental health, can be to not disclose problems to people outside of the family, or a refusal to acknowledge a family member’s suffering.

November 2008

We’re sitting on the red couch in the room with the red rug and the red curtains and the red candles and we’re watching something stupid like Gossip Girl and little Ryan with her dainty arms and bony wrists starts sobbing and I ask her why she’s crying but she won’t say anything and just keeps shaking her head and it isn’t until I also start crying because I’m so scared of her sobbing that little Ryan rolls up her sleeves to reveal thin red lines of congealed blood all over her dainty arms and bony wrists. Why are you doing this I ask Ryan and she tells me it’s because she’s always very sad and hates it here and I tell her that she can say the word and we can leave and never come back to this awful house and she tells me no and that by here she meant the world and wishes she just didn’t exist anymore.

Don’t say that I tell her because now she’s really scaring me. I hug her and I tell her that I’m going to get her outside help from a professional and she shakes her head again because she doesn’t see how that’s possible since mom and dad don’t approve of us telling other people our problems and they think therapy is for crazy people and we’re not crazy people. I tell her I will get her help once I get my paycheck from the local clothing store I work at and once I turn eighteen in a few weeks I can be her legal guardian and mom and dad won’t ever have to know about the therapy but she just keeps crying and tells me that she doesn’t think she can wait that long so I just hug her until we finally stop crying and go back to watching Gossip Girl.

2) Sometimes in conjunction with familismo lies marianismo, which is defined as an idea of female gender role that emphasizes nurturance and self-sacrifice. It is usually manifested as the tendency for Mexican females to take on so much responsibility that they feel burdened. Familial obligations preclude the female from taking care of herself. [4]

March 1991

My mom is sitting with my grandmother and she talks on and on about my mom’s brother and how he just got a fantastic job as a principal at some engineering firm and now makes more money than my mom and drives a Porsche and my mom tells my grandmother that she doesn’t even know what a Porsche is and my grandmother tells my mom that she’s right but that nonetheless a Porsche sounds very fancy and important and my mom is sitting there trying to not scream in my grandmother’s face or throw something across the room or storm out of the house but the more my grandmother goes on the less restrained my mom feels.

Eleven years with the same huge corporate law firm had finally gotten her a very fancy partnership with all kinds of benefits and she had managed to get this partnership not only as a woman but also as a Latina and not only as a Latina but in the same year that she was pregnant and subsequently gave birth to me so my mom doesn’t quite understand how a Porsche could be more important than her partnership but my mom ends up sitting there and waiting until my grandmother finishes raving about my mom’s brother and once my grandmother finishes talking my mom tells her she was just appointed by the old rich white Republican mayor of Los Angeles to be president of the city’s police commission which will be a big time commitment but the police force in the city seems to be stable enough that it won’t take her away too much from her family or me the newborn daughter but that night she gets her first assignment as President of the Los Angeles Police Commission when the media gets ahold of an alleged police brutality story involving some black man named Rodney King.

3) Particularly with Mexican-Americans, the influence of prior experiences with psychological treatment will provide a clue as to whether or not an individual will seek mental health help. [5] This is, yet again, due to the stigma in Mexican culture surrounding therapy.

 May 2002

I’m in the fifth grade and I have a crush on a boy on my class named Chris and it’s the first time I’ve never had a full-blown crush on any boy so I fall pretty hard for him but fall even harder when I find out he’s going to the park after school to kiss another girl in our class who doesn’t have frizzy hair and isn’t gawky like me.

The day I find out about Chris and this other girl I come home and cry a lot and my mom rolls her eyes and tells me to get over it and to get a tougher skin but that only makes me cry harder so then my mom tells me that I’m crazy and that I’m sick and that I need help so she sends me to a therapist named Cheryl who works out of her house and seems very nice and always gives me candy but one day after a few months of seeing Cheryl my mom and I get into a fight in which she informs me that she knows everything I’m saying in therapy because Cheryl has told her and I realize later on in life that this is unethical and that Cheryl was probably just my mom’s friend and not a therapist but at this time I decide that therapists are good for nothing and even the supposedly crazy people like me can’t trust them.

4) My mother is an immigrant, and my sister, my father, and I are all children of immigrants. Immigrants, as research shows, have increased psychotic symptomatology and rates of depression in comparison to natives. [6] Beyond that, my mother is a rural immigrant who comes from two rural immigrant parents. Research shows that in these circumstances, psychotic symptomatology and rates of depression are compounded. [7]

 July 2007

My mom seems to be looking at herself in the mirror but really she’s looking at the photo of a pile of millions of dollars that she had printed out and taped up in the bathroom so she wouldn’t forget that money was the most important thing in life which to some people might seem shallow but those people probably didn’t grow up in a tiny rural town in a tiny farm house where they had to share a room with their parents until they were fourteen and their mother made all their clothes since their parents couldn’t afford to buy new ones and their father was a janitor when they were in high school and tried to talk to their friends in his very broken English during passing periods but that was certainly how she grew up so money was the most important.

My mom thinks about those other people and their childhoods and then she thinks about her own and she starts crying because it’s all so unfair so she takes some of the un-prescribed medication she got from a doctor friend and stops crying and feels nothing for a little bit.

Apparently therapy is about the situation at hand, so we consider none of this.

We only had ten sessions of family therapy, rife with screaming, pointing fingers, running out of the room, and long silences. Four years later, we have distanced ourselves from this time, whether by physically moving far away, like me, or ignoring it, like my father. But we are still a family of screaming, pointing fingers, running out of the room, and long silences. We cannot be “cured” so to say, without cultural competence.

By: Kate Holguin, Features Editor

References:

[1] Rage blackouts are a type of memory loss due to fits of rage, which almost entirely impair social skills. There are fourteen conditions associated with rage blackouts, including medication reaction or side-effect, bipolar disorder, and schizophrenia. (Courtesy of WebMD Symptom Checker. “Blackouts (memory time loss), Fits of Rage, Impaired Social Skills and Impulsive Behavior: Common Related Medical Conditions.” Web. 13 April 2013. ). 

[2] J.E. Mezzich, A. Kleinman, H. Fabrega and D.L. Parron, Culture and psychiatric diagnosis: A DSM-IV perspective (Washington D.C.: American Psychiatric Press, 1996), 5-11. 

[3] Rachel Zack Ishikawa, Esteban V. Cardemil and Rachel Joffe Falmagne, “Help Seeking and Help Receiving for Emotional Distress Among Latino Men and Women,” Qualitative Health Research 10 (2010): 1558-1572.

[4] Rachel Zack Ishikawa, Esteban V. Cardemil and Rachel Joffe Falmagne, 1558-1572.

[5] Rachel Zack Ishikawa, Esteban V. Cardemil and Rachel Joffe Falmagne, 1558-1572.

[6] P. Fossion, L. Servais, M.C. Rejas, Y. Ledoux, I. Pelc and P. Minner, “Psychosis, migration and social environment: an age and gender controlled study.” European Psychiatry, 19, 338-343.

[7] Teresa Kirchner and Camila Patiño, “Latin-American Immigrant Women and Mental Health: Differences according to their Rural or Urban Origin,” The Spanish Journal of Psychology, 14, 843-850.

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