Family therapies within the context of a culturally diverse - Youthline

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Family Therapies within the Context of a Culturally Diverse New Zealand

The evolution of Family Therapy The origins of family therapy were based on a paradigm proposed by Talbot Parsons in 1954, which held a highly structural and functional view of the family. The characteristics believed to constitute a functional family involved establishing clear and distinct roles for men and women, with the nuclear family1 providing the accepted standard. (Canino, I.A. & Inclan, J.E., 2001) This view of the family was considered universal and thus applied across diverse groups equally (Canino, I.A. & Inclan, J.E., 2001). Within the field came a gradual movement away from this culturally insensitive, male dominated model to a context dependent, culturally aware field in which ‘family’ can be understood in a range of ways. Corresponding to the evolution of the field of family therapy has been the advancement of culturally sensitive and competent approaches. This paper will consider the application of family therapy within the context of New Zealand’s cultural diversity, with a focus on the fit with principles of youth development. Current research into the cultural context of family therapy Research into the cultural context of family therapy mainly focuses on the therapeutic alliance developed between therapist and clients of different ethnic backgrounds, often creating a comparison with culture-matched alliances. Studies on cross-cultural therapy emphasise that the therapist must overcome experiences of cultural dissonance by developing cultural competence. This involves being aware of cultural beliefs and values that differ to their own. The knowledge and skills of the therapist must then be translated into behaviour to achieve cultural competence, and for the therapist to practice context dependent therapy (Canino, I.A. & Inclan, J.E., 2001). Best practice evidence also cautions 1

The Nuclear Family: in its most common usage, the term "nuclear family" refers to a household consisting of a father, a mother and their children.

against service providers developing a false understanding that members of a particular group are homogenous. This assumption is likely to result in cultural stereotyping. A key text in this specialty is Monica McGoldrick’s, Ethnicity and family therapy (3rd ed.), which details the characteristics and cultural values that distinguish over 40 distinct ethnic groups. As with much of the literature in this field, McGoldrick’s text is primarily written for an American audience and does not account for Maori and some Pacific cultures (Monica McGoldrick, 2005). There is little discourse however, surrounding the cultural compatibility of therapeutic models when applied with families of diverse cultures. The Werry Centre, Auckland are currently undertaking a literature review of family therapy models, inclusive of those models used in Aotearoa/New Zealand that demonstrate cultural competence within the New Zealand context. This paper is an initial theoretical assessment only, which will consider the principles underlying each model of family therapy within the context of diverse ethnicities, cultural practices and principles of youth development. New Zealand’s Cultural Context New Zealand has an increasingly diverse cultural society which is based on a bicultural discourse. This is an expression of the partnership between the Tangata Whenua (the people of the land – indigenous Maori people) and Tangata Tiriti (non-Maori settlers) established in the signing of the Treaty of Waitangi in 1840. Bicultural New Zealand originally comprised Maori and Pakeha (non-Maori, mainly of British decent). In recent decades, New Zealand has become home to a multiplicity of nationalities, including Pacific Island People, Asian, Middle Eastern, European and African, each presenting their own set of values and belief systems. Bicultural New Zealand is now discussed interchangeably with concepts of a multicultural New Zealand (Phillips, 2009). Further variables influencing families in New Zealand may include acculturation issues such as migration stress, changes in status, language barriers, and changing generational assumptions of culture and expectations. Culture is a dynamic concept, within which belief systems regarding health, illness and behaviour may differ widely. New Zealand’s Family Context

The notion of ‘family’ is one inextricably bound to the cultural context in which individual family units are understood. New Zealand’s wealth of ethnicities and cultural variations highlights the importance for practitioners to consider family therapies within the context of culture and preferences. Differences in the concepts and underlying values of family are observable between each ethnic group. A broad understanding can be gained from considering the notions of individualism and collectivism and the related ideals that underpin cultural mores. Traditionally, western cultures place emphasis on principles of individual self-determination rather than on extended family or collective concepts of selfdetermination. In New Zealand, these values will be relevant and integral to many families. Other families, particularly Maori and Pacific Island families favour notions of familism; i.e. the importance of extended family and collective ideals. Whanau Historically, whanau comprised immediate and extended family members, spanning across the generations, creating multigenerational households. There is a disparity between traditional ideologies surrounding Te Reo Maori Whanau and the postcolonial reorganisation of social structures, which resulted in a shift of family structures to one that more resembled the nuclear family. This shift has resulted in tension between the applications of Western models of family therapy within Maori whanau. The process of redressing this disparity is underway with the application of Maori Health models and practices that are aligned with Maori whanau. The frameworks of models such as Te Whare Tapa Wha ( (Durie, 1998) enable therapists to reflect Maori health philosophy when conducting family therapy with Maori clients; this helps ensure culturally appropriate practice and support. Samoan Families This issue of family therapies being conducted in culturally inconsistent ways is particularly salient for Samoan families for whom the concept of the self can only be understood and have meaning within the context of relationships with other people, rather than as an individual.

“This self could not be separated from the ‘va’ or relational space that occurs between an individual and parents, siblings, grandparents, aunts, uncles and other extended family and community members” (Tamasese, K., Peteru, C., Waldegrave, C., Bush, A., 2005). The above extract is taken from a recent New Zealand study of Samoan perceptions into health care, which identified the Samoan view of self as a fundamental concept for achieving culturally appropriate services for Samoan people. The involvement of extended family members in treatment was emphasised as being particularly important (Tamasese, K., Peteru, C., Waldegrave, C., Bush, A., 2005). Further, the Samoan family structure follows a hierarchy. The father is the patriarch of the family and next to him is the mother; the children follow in the hierarchy from oldest to youngest. The concept of Faaaloalo governs this hierarchy; Faaaloalo is respect and this value is inherent in all aspects of Samoan culture, especially with regards to the hierarchy of the family. This is a model that differs widely from western family structures. To summarise, family relationships in New Zealand encompass a multitude of concepts, beliefs and understandings. These include notions of identity, belonging, heritage, family processes, interactions, multigenerational identity, and distinct cultural mores. Values, gender roles and discipline practices may differ widely between families of different cultures. The implications are that no one family system is correct, but that all family systems should be accounted for when applying family therapies. As a result, practitioners need to contextualise their understanding of the family so as to provide a culturally sensitive approach. Family Therapy: An Overview Models of family therapy have been emerging and evolving since the 1950s and the most widely accepted therapies present an approach that integrates constructs from a range of theoretical models. Intervention strategies in Multisystemic Therapy (MST) for example, merge Strategic Family Therapy, Structural Family Therapy, and Cognitive Behaviour Therapy (CBT). (Henggeler, S.W.; Borduin, C.M, 1995). Further, clinicians often take a blended model of problem-focused treatment, such as MST and combine their approach with elements from other related models. This dynamic approach affords therapists the freedom to adapt treatments to suit individual families.

The appropriateness of a family therapy depends on the extent to which the approach aligns with the cultural mores specific to that family. A fundamental understanding of the way ‘family’ is defined must first be established in order to identify the therapy most suitable to that family and culture. The dichotomy of individual and collective concepts exposes an inequality in the treatments available, which Charles Waldegrave, leader of the Family Centre Social Policy Research Unit, argues manifests in the statistical measurement of outcomes in New Zealand. Waldegrave’s recent article in the Family Processes Journal attributes the consistently poorer than mainstream social, educational, health, and economic indicator results for immigrant and indigenous people to this inequality. Specifically, Waldegrave identifies a discord between immigrant and indigenous cultural perspectives toward learning, socialisation, and economic activity and the mainstream perspectives that are largely used to approach these issues (Waldegrave, C., 2009). To redress these issues, family therapy must afford change, irrespective of the ethnicity of the family. To achieve this, models of therapy must be responsive to the needs and beliefs of different cultural groups. Family Systems Therapy The most common approach to family therapy is based on family systems theory. A systems approach takes an organic view of the family, thereby emphasising the interconnectedness of family members as parts of a whole family system, rather than focusing on individuals. Treatment involves considering the systems unique to the family in therapy and the internal rules and patterns of functioning by which their system operates. Difficulties faced by one family member (the identified patient) may be an outcome of an unproductive function within the system. Introducing change into the system is theorised to bring change to the individual by making healthy the whole. By not relying on a prototype model of a typical family, Family Systems Therapy (FST) is responsive to diverse conceptions of what constitutes a family. Due to the dynamic and holistic approach of systems theory, many of the underlying principles align well with the concept of family within a variety of cultural perspectives. The underlying philosophy of systems therapy is consistent with collective cultures by working together with the family. The autonomy and dignity of the individual is also preserved within this approach, thus aligning with selfdeterministic concepts of individualistic societies also. This is particularly salient in the concept of differentiation in family systems therapy, whereby individual family members maintain their own sense of self, while remaining emotionally connected to the family. Therapists working with Samoan families

should be cognisant of beliefs surrounding concepts of the self before introducing ideas of differentiation. Differentiation is one of five concepts of systems theory. Each of these has the scope to be understood within a culturally competent and consistent way. The principles of youth development, as outlined in the Youth Development Strategy Aotearoa (Ministry of Youth Development, 2007)are also supported to an extent. Identified Patient The identified patient is the family member presenting an issue and is typically a young person. Rather than concentrating on the individual, therapists consider the factors in the system that may have contributed to the problems. This permits a shift from family dysfunction being focussed exclusively on the behaviour of the young person, to the influence of family dynamics. Such an approach is consistent with a strengths-based perspective, although it does not specifically address the young person’s strengths. Perhaps because the young person is seen as a part of a system in which cause and effect of behaviour cannot be separated, rather than an individual who is influenced by a range of overlapping systems, FST cannot be considered explicitly strengths-based. Homeostasis This concept refers to the tendency for the family system to resist change to the established organisation and functioning in order to maintain homeostasis or balance. The premise for this concept is that by reorganising parts of the system, the problems that have emerged can be resolved. A potential shortfall of this therapy within a cultural context is that many families will be deeply rooted in the family’s cultural values; change therefore, may imply a contradiction to their cultural ethos. This concept supports youth development principles by recognising the importance of the social and cultural context when working with young people. Related to this is the significance of young people being connected, including within family relationships. Family systems therapy naturally supports these principles. However, there is the potential for family systems therapy to give significance to the family system at the expense of understanding other systems that the young person interacts with. Presumably, family dynamics are problematic for families engaged in therapy; however some caution

should be exercised to view the wider ecological context of the young person. While families are critical, young people are also involved in social systems, school systems and community. How these systems interact with the family system may be critical. The Extended Family Field This concept refers to family that extends beyond the nuclear family, including Grandparents, cousins, and other networks of relations. The concept of the extended family field is introduced to system therapy to explain the intergenerational transmission of attitudes, problems, behaviours, and other issues. While recognition of the importance of extended family is consistent with many cultures, by identifying the extended family field as an associated concept, it is indirectly assumed that this model is designed with the nuclear family in mind. In many cultures, including Maori and Pacific Island, family is understood to be inclusive of extended family/whanau. This is an important cultural consideration that must be identified before therapy commences in order to accurately represent and understand the family system in question. Triangular Relationships Family systems theorises that when difficulties arise between the relationships between two family members, a third becomes part of the dynamic in order to stabilise the relationship. This is referred to as a triangular relationship. FST demonstrates potential to be responsive to different cultural needs and shows a reasonable fit to principles of youth development. Many of the strategies involved are conducive to youth development and a strengths-based perspective is employed, although this doesn’t specifically relate to the strengths of the young people. The deficits of FST within a youth development framework are a potential lack of focus on systems other than family that may affect young peoples’ behaviour; an emphasis on circular behaviour that may not be helpful in understanding behavioural problems in young people; and, an implied rather than explicit strengths-based paradigm.

Multisystemic Therapy Multisystemic therapy (MST) is an intensive therapy for young people with severe psychosocial and behavioural problems (Littell, Campbell, Green, & Toews, 2005). MST combines aspects of family systems with the other ecological factors influencing a young person’s life. MST also explicitly considers the ecological correlates of antisocial behaviour (Henggeler, Schoenwald, Rowland, & Cunningham, 2002), indicating a different focus than family systems. Specifically, MST addresses the factors in young peoples’ lives that may be contributing to delinquent behaviour. Evidence for the effectiveness of MST is emerging, although is not definitive. While some narrative reviews have indicated that MST is a particularly effective form of therapy, the only meta-analysis and systematic review (Littell, Campbell, Green, & Toews, 2005) indicates that, overall, no significant differences could be identified between MST and standard interventions. The differences may have resulted from the narrative review focus on positive results, compared to meta-analysis focus on overall trends. Littell et al. note, however, that their analysis had little power to determine a significant difference if one does exist. As such, more high-quality studies are required to determine the relative effectiveness of MST. Littell et al. were criticised by MST’s principal researchers (Henggelera, Schoenwald, Borduin, & Swenson, 2006), however Littell (2006) subsequently refuted these criticisms, leaving the 2005 meta-analysis the most comprehensive assessment of MST. As Littell notes, most of the evidence base for MST has been generated by its developers, which is potentially problematic as they have substantial vested financial interests in its success. Nonetheless, since Littell et al.’s meta-analysis, a New Zealand study has indicated MST is effective with juvenile offenders both in terms of re-offending and family relations (Curtis, Ronan, Heiblum, & Crellin, 2009). The ethnic composition of this sample was 83% New Zealand Pakeha, 9% Maori, 3% Samoan and 5% other; conclusions cannot therefore, be derived with regard to effectiveness of MST across different cultures (Curtis, Ronan, Heiblum, & Crellin, 2009). MST addresses some aspects of youth development that do not fall naturally within the family systems approach. One of the nine principles of MST explicitly states that interventions should focus on the positive (Henggeler, Schoenwald, Rowland, & Cunningham, 2002). This indicates a strengths-based approach is explicitly integrated in MST. This form of family therapy also emphasises that treatments should be developmentally appropriate and build on competencies that will be conducive to successful transition into adulthood, which is consistent with principles of youth development. Further, MST

employs strategies that encourage cooperative partnering within families. Quality relationships are identified in the YDSA as being instrumental to positive youth development; therefore this is another example of MST being a good fit with principles of youth development. MST also directly acknowledges a range of ecological and social factors that affect and interact with a young person’s behaviour. This supports the first principle of the YDSA, acknowledging that young people must be seen with ‘the big picture’. This element of MST also affords the treatment potential to adapt to working with different cultural groups. By recognising pertinent systems in the young person’s life, culturally significant factors, such as extended family, iwi and church can be involved. However, it is not currently clear how responsive MST is to factors beyond the control of the young person. The founders of MST assert that it is a model that is responsive to families needs. An open approach to understanding family systems is fundamental when working with diverse cultures; hence there is scope for MST to fit well with a range of ethnicities. A conscious effort has been made in New Zealand to ensure MST is practised in a culturally appropriate way that is responsive to the needs of Maori. To achieve this, an Aotearoa specific MST organisation exists which addresses the needs of New Zealanders when implementing this type of family therapy. The following considerations are identified as being fundamental to practising MST with a Maori family: Tikanga mo nga Hapu me nga Iwi (protocols of dealing with tribes and sub-tribes) Tino Rangatiratanga (sovereignty) Whakawhanaungatanga (relationship building) Whanaungatanga (extended whanau) Taha Wairua (spiritual well-being) Taha Hinengaro (mental well-being) Taha Tinana (physical well-being) Taha Whanau (whanau well-being) (MST New Zealand) This demonstrates the ease with which MST can be understood within different cultural frameworks and family structures. Although this example is for Maori only, the adaptability of MST is encouraging for practitioners working with other cultural groups.

Functional Family Therapy Functional family therapy (FFT) is an approach developed over several decades that is used as both a preventative measure and an intervention for at-risk young people and their families (Sexton & Alexander, 2003). Along with MST, it is increasingly used following a young person’s involvement with the justice system (Long, 2007). Sexton and Alexander state that FFT formed from a need to address issues in families that were resistant to traditional models of treatment. FFT differed from traditional approaches by attempting to understand the causes of resistance in families and addressing them, rather than focussing on behavioural patterns. The underlying constructs of FFT align particularly well with the YDSA, providing a model that can be effectively implemented within the framework of the YDSA in New Zealand. FFT works from an explicitly strengths based perspective, providing an assessment of the risk and protective factors influencing the young person. This approach directly corresponds with the third principle of the YDSA. From a strengths based perspective, FFT promotes engagement and motivation in family members, with the aim to bring about positive change. This reflects the fifth principle of the YDSA, which states that youth development is triggered when young people fully participate. Congruence is also evident in the paratreatment phase of FFT, which emphasises the importance of establishing a network of sources and multidimensional (e.g., medical, educational, justice) systems to surround the young person and their family. The YDSA attributes ‘being connected’ to positive youth development, and can be achieved using a FFT model. Further, clinical difficulties are considered multisystemically by FFT. This provides a model that acknowledges the importance of context when working with young people. This demonstrates another alignment with the YDSA in that youth development is shaped by the big picture, which includes the young person’s values and belief systems as well as their social, cultural and ecological contexts. This demonstrates that FFT is an empowerment model that has a good fit with the YDSA and therefore promotes positive youth development. The suitability of this model to a range of cultures can also be evidenced.

The clinical model proposed by the founder of FFT describes an “FFT Attitude”; this comprises 6 core principles, the first of which refers to cultural competency and awareness as, “a core attitude of respectfulness of difference, culture, ethnicity, (and) family form”. This ethos is translated in therapy by the therapist encouraging and motivating families to work towards acceptance of their own ‘model’ or understanding of family, rather than apply an external model of behaviour as a goal for treatment. This approach avoids imposing culturally inconsistent theories and treatment goals on families by not presupposing notions of ‘family’ and culture. This, combined with the good fit with youth development principles makes FFT a viable intervention option for at risk youth of any culture in New Zealand. FFT argues that variations in culture, family configuration and generational learning patterns produce a wide range of relational patterns, which in turn may create behavioural outcomes, both positive and negative. This understanding is especially important within a New Zealand context, where definitions of what constitutes a ‘family’ are diverse and family structures varied. From a Samoan perspective, for example, relational functions are hierarchical; An FFT model would not seek to re-establish familial structures in this case; instead the priority would be to enhance positive relational patterns in order to empower the young person. Conclusions The trend in family therapy has been towards blended, pragmatic approaches that have the potential to be as dynamic as the families with whom they are used. Approaches such as FFT and FST may provide the best solution for therapists to provide a culturally viable service that has a good fit with the model of youth development proposed in the YDSA. These therapies offer a set of techniques that can be applied with a variety of cultures and within the world view of individual families (Richeport-Haley, 1998). Therapists may feel it appropriate to take a blended approach and incorporate other therapeutic elements that may benefit a particular family. A study into the cultural competence of different family therapy models reveals strengths and weaknesses in all with regards to them being relevant and applicable cross-culturally.

Family systems theory is well-aligned with cultures where interdependence between family members is important, while also respecting the autonomy of the individual. By acknowledging the value of both collective concepts and self-determination, there is potential for this therapy to be appropriate for a mix of ethnic groups. The extent to which concepts of differentiation (maintaining sense of self from other family members) are employed in therapy will depend on specific cultural mores. An implicit assumption of family systems is that therapy will initially work with the immediate family members; however the importance of extended family is recognised as an associated system. Therapy using this approach can be easily modified to understand the family in terms of encompassing extended family members/whanau. Unlike family systems, MST and FFT consider spheres of influence including and beyond family systems. This allows greater opportunity to work with systems that are culturally important, including church and iwi. This has been explicitly addressed in MST, with New Zealand specific consideration being addressed by a guidelines group. FFT demonstrates cultural competence particularly well by encouraging families to work toward their own model of family, rather than applying an external model of behaviour as a goal for treatment. Cultural stereotypes are avoided and inconsistent ideals are not enforced. It is difficult to evaluate the relative fit of either FFT of MST with the principles of youth development and conclude that one is superior. Each has its own emphases, and each have strengths in different situations. Family systems is a good approach, and forms the basis of FFT, however it is not quite as well matched with the YDSA as either FFT or MST. Overall, both FFT and MST appear to have arisen from similar need and be similarly suited to the needs of families of young people with severe behavioural problems. Generally, FFT is well suited to young people and their families where it is evident that the family system is the primary cause of the problems that have initiated therapy. MST is well suited to situations where the family system is a contributor, but other systems must be equally recognised as important as underpinning behaviour in the young person. It is important to consider how well different approaches are supported by evidence, as well as their suitability to cultural diversity and fit with youth development principles. The weaknesses of both FFT

and MST are that their evidence bases are largely the result of single research groups, although more local evidence bases are also evolving. As McGoldrick emphasises, developing a therapeutic alliance with clients is paramount and this may be facilitated by employing skills of cultural competency. Indeed some clients may prefer or require (if language barriers present) a culturally matched therapist. These skills, combined with an approach that demonstrates cultural competency by being responsive to the needs of different ethnic groups, without imposing assumptions about family structure, will ensure practitioners address the needs of unique families, from different backgrounds.

References Canino, I.A. & Inclan, J.E. (2001). Culture and Family. Child and Adolescent Psyciatric Clinics of North America , 601-613. Curtis, N., Ronan, K., Heiblum, N., & Crellin, K. (2009). Dissemination and effectiveness of multisystemic treatment in New Zealand: a benchmarking study. Journal of Family Psychology, 23 , 119-129. Durie, M. (1998). Whaiora: Māori health development. Auckland: Oxford University Press. Edwards, S. McCreanor, T., Moewaka-Barnes, H. (2007). Maori family culture: a context of youth development in Counties/Manukau. New Zealand Journal of Social Sciences Online . Guamaccia, P., and Parra, P. (1996). Ethnicity, Social Status, and Families’ Experiences of Caring for a Mentally ill Family Member. Community Mental Health Journal , 243-260. Henggeler, S., Schoenwald, S., Rowland, M., & Cunningham, P. (2002). Serious emotional disturbance in children and adolescents: multisystemic therapy. New York: Guilford Press. Henggeler, S.W.; Borduin, C.M. (1995). Multisystemic treatment of serious juvenile offenders and theirfamilies. In I. A. Schwartz, Home-based services for troubled children (p. 121). Lincoln Nebraska: University of Nebraska Press. Henggelera, S. W., Schoenwald, S. K., Borduin, C. M., & Swenson, C. C. (2006). Methodological critique and meta-analysis as Trojan horse. Children and Youth Services Review , 447-457. Littell, J. H. (2006). The case for multisystemic therapy: evidence or orthodoxy? Children and Youth Services Review , 458- 472. Littell, J., Campbell, M., Green, S., & Toews, B. (2005). Multisystemic Therapy for social, emotional, and behavioral problems in youth aged 10-17. Cochrane Database of Systematic Reviews , Issue 4. Long, W. J. (2007). An examination of multisystemic therapy and functional family therapy treatment models targeting youth demonstrating at-risk, criminal and violent behavior utilized to reduce out of home placement including foster care and incarceration. Unpublished MA thesis, State University of New York. Ministry of Youth Development. (2007). Youth Development Strategy Aoteroa. Wellington: Ministry of Youth Development. Monica McGoldrick, J. G. (2005). Ethnicity and family therapy (3rd ed.). New York: Guilford Press. MST New Zealand. (n.d.). Multisystemic Therapy: Treaty Obligations. Retrieved June 14, 2010, from Multisystemic Therapy New Zealand: http://www.mstnz.co.nz/treaty.htm

Phillips, J. (2009, March 4). 'The New Zealanders - Bicultural New Zealand' & 'The New Zealanders Multicultural New Zealand'. Retrieved May 19, 2010, from Te Ara - the Encyclopedia of New Zealand: http://www.teara.govt.nz Richeport-Haley, M. (1998). Ethnicity in Family Therapy: A Comparison of Brief Strategic Therapy and Culture Focused Therapy. The American Journal of Family Therapy , 77-90. Sexton, T. L., & Alexander, J. F. (2003). Functional family therapy: a mature clinical model for working with at-risk adolescents and their families. In T. Sexton, G. Weeks, & M. Robbins, Handbook of Family Therapy (pp. 323-348). New York: Brunner-Routledge. Tamasese, K., Peteru, C., Waldegrave, C., Bush, A. (2005). Ole Taeao Afua, the new morning: a qualitative investigation into Samoan perspectives on mental health and culturally appropriate services. Australian and New Zealand Journal of Psychiatry ; , 39, 300–309. Waldegrave, C. (2009). Vol. , No. 1, 2009 r FPI, Inc. (results based on those published by the Ministry of Social Development, 2006). Family Process , 48, 85-101. Waldegrave, C. (2009). Vol. , No. 1, 2009 r FPI, Inc. (results based on those published by the Ministry of Social Development, 2006). Family Process , 48, 1-3.

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Family therapies within the context of a culturally diverse - Youthline

Family Therapies within the Context of a Culturally Diverse New Zealand The evolution of Family Therapy The origins of family therapy were based on a...

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