Case Study of Martinez Family - Chapter 21

A family therapy research program focusing on drug abuse in a large metropolitan city on the West Coast included 41 families, 16 of which were Latino. The clients were affected by a variety of psychological disorders, and all had histories of drug abuse. The Latino families in the program came from a wide range of Latin American countries. The research program entailed 10 sessions of family intergenerational therapy that was manual based and conducted in a bilingual format. The Latino participants were all second-generation immigrants (i.e., the children of immigrants to the United States).

During the course of the therapy, a number of issues came up, as illustrated by the material presented here. Most of the Latino families were struggling with challenges related to immigration, family roles, and separation from the nuclear and extended family, in addition to the challenges of drug abuse. Nearly all of the Latino families were facing issues that often emerge in family counseling and therapy with linguistically and culturally different clients. As an example, we present the case of the Martinez family. Identifying details of this family have been altered to protect anonymity. The Martinez family consisted of Victor, the 33-year-old "identified patient," and the family members with whom Victor lived: his 57-year-old mother and his 36-year-old sister, both divorced; a 10-year-old nephew; and a great aunt, 84 years old.

Victor's extended family included an older brother (age 40) and the brother's wife and children. Victor had a history of heroin abuse since adolescence. At the moment of entering the family therapy treatment, he was in a methadone maintenance program, yet he admitted to continued casual use of heroin. He was disconnected or cut off from his father. Victor's older sister, Patricia, was the breadwinner of the family; Victor did not finish high school and could not hold a job for more than a few weeks. Victor's mother received Social Security benefits and helped support Victor, which included giving him money for his drug use. She was worried about the shame that would come to her family if Victor were arrested for a crime and convicted, so she preferred to give him money to prevent his committing a crime.

Later it became clear that the vergüenza, or shame, would be particularly bad for the older brother, who was a law enforcement officer. When Victor was 5 years old, he and his mother lived with his grandmother and Patricia in Nicaragua; his mother then migrated to California alone before gradually bringing her children to join her, beginning with her daughter. It took 9 years for Victor to be reunited with the rest of his family.

An examination of the family genogram showed a three-generation pattern of losses and separations, with women in charge of the family but without much help from their male partners, who were involved in alcohol abuse. Victor's mother left Nicaragua to improve the family's economic situation and left the children behind under the care of the grandmother. The women were seemingly overinvolved and enmeshed with their children. Gradually, the mother began to bring the children to the United States, first her daughter and later the grandmother and Victor. One of the key elements in family counseling is engaging the family.

The research context in this case provided a great deal of flexibility with regard to making reminder calls to the family about appointments or even holding sessions in the home if necessary. The sessions with the Martinez family were conducted in both English and Spanish. The older members of the family were addressed in Spanish, and the younger ones spoke English. Language can be a powerful tool for engaging the less acculturated members of a family. Deciding which family members to invite is also important. From an intergenerational perspective, the ideal approach is to invite anyone who is available and can help. These invitations are not left up to the identified patient or any other family member.

In the case of the Martinez family, the counselor obtained the necessary contact information and called the potential participants, inviting them to one session. With Latino families, the value of familismo often means that family members will show interest in being part of at least a first session. Soon thereafter, the use of the genogram helped to broaden the family members' views of their situation. An early task assigned in therapy was for all family members to engage in the joint project of diagramming their family tree as far back as possible. The diagram was later discussed in a session with all members present. Discussion This case illustrates many of the complexities involved in counseling families.

A first concern was how to handle the integration of a serious substance abuse condition within the psychological, family, and social contexts. Our approach was based on a family therapy strategy that incorporates culture and context. We used the contextual family therapy (CFT) model, which aims to include all available individuals in its preventive strategies (Boszormenyi-Nagy & Ulrich, 1981) for the benefit of current and future generations.

We culturally adapted the approach as suggested by Bernal and Domenech Rodríguez (2012). CFT views drug abuse as predominantly rooted in social and community processes that affect the entire family. Second, we needed to culturally adapt and contextualize notions about high levels of interpersonal involvement among family members, often viewed as "enmeshment" and considered pathological and indicative of overly flexible boundaries.

When mothers become single parents, left to take care of their families on their own, how is it possible for them not to be "overly" involved with their children? Here we see that Victor's mother assumed both instrumental and affective roles. And given the cultural context of familismo (valuing the unity of the family), we needed to culturally adapt and contextualize the pathological concepts of enmeshment, fusion, and undifferentiated ego mass. A third consideration is the immigrant experience, which includes the intergenerational conflicts that evolve from the pressures on the younger generation to assimilate, adapt, and/or acculturate.

With migration comes the loss of social capital and disconnection from the family of origin and the network of relationships at home. In this case, a number of relational issues arose. Victor's mother migrated alone to the United States from Nicaragua with hopes of improving the economic situation and quality of life of the family; that by itself is a courageous endeavor for anyone and in particular for a woman from a context of limited resources and education. She left her children to be raised by her mother when Victor was 5 years old.

The therapy supported Victor and his mother in talking about the losses they had experienced and ways for the mother to give to her son directly that did not entail paying for his drug use, perhaps as a way to make up for having left him. At the same time, Victor's contribution was recognized as a sacrifice-that is, through his addiction he seemingly remained dependent on the family as a way to give to his mother. The effort here was to build trust in family relationships.

Could the contributions of each member of the family be recognized, and could a plan be devised based on an understanding of the legacy of abandonment, limited resources, and loss? Once mother and son exonerated each other, the focus of the therapy turned to identifying resources and problem solving for all family members. Finally, the genogram was a resource for exploring the family's history and changing contexts. From the genogram it was clear that the family had a three-generation pattern of women leaving children with their mothers, serious challenges with men suffering from alcoholism and subsequently abandoning the family, and overinvolvement of women with their children.

A broader contextual view emerged in which all were understood to be victims of a legacy of poverty, war, and exploitation. The question became what they could do about it now, and the promise of therapy was that they could learn how to transcend the generational legacy to prevent the younger generation from further victimization.

What definition of "family" would you use in this case? How would you describe the structure of the Martinez family and the impact of social, historical, and cultural processes on the family's basic functions (e.g., instrumental, expressive, child rearing)?

What conceptual resources or tools could help you approach a family that is different from your own racial, ethnic, and cultural background, given the changing social, historical, and multicultural contexts?

What is your assessment of the Martinez family intervention? What other culturally sensitive approach might have been suitable for this family, and what would you have done differently?