The United States is now an ethnically complex society. The demographic changes that have taken place in America during the past five decades have given rise to a country where cultural and ethnic diversity is becoming the rule, rather than the exception. These changes are also evident in the field of mental health, where psychiatrists and other practitioners are finding that "a patient-therapist cross-cultural dyad now constitutes the modal unit" (Arce, 1993). Psychiatrists treating recent immigrants should always ask themselves the following questions: To what part of the United States has the person immigrated? Which racial, cultural, socioeconomic, or climactic variables has the immigrant encountered and how do these differ from his or her own?
Hispanics are the largest and fastest-growing minority group in the United States, and Hispanic adolescents are the largest and fastestgrowing minority in this particular age group. This chapter reviews the available psychiatric literature on Hispanic American adolescents and their families. It focuses on issues such as the experience of migrating to the United States, the experience of being a Hispanic adolescent refugee, the process of acculturation, and the transformations of identity experienced by Hispanic adolescents in the United States. In addition, the effects of poverty, substance abuse, risk of HIV, and other social Stressors on Hispanic adolescents and their families are discussed.
Finally, this chapter outlines treatment considerations that allow the non-Hispanic psychiatrist to better understand issues of transference and countertransference and to design treatment interventions that are culturally sensitive and that facilitate the successful engagement of the Hispanic adolescent and his or her family in the treatment relationship.
THE NEW DEMOGRAPHICS OF HISPANIC AMERICANS
The term Hispanic first came into common use in the United States in the 1980s, when demographers began utilizing the term to define a fast-growing but heterogeneous segment of the U.S. population (SuarezOrozco and Suarez-Orozco, 2001). It has been used loosely to define individuals who descend culturally from the inhabitants of Spain, regardless of their race.
There are presently 35.2 million Hispanics in the United States, constituting 12% of the country's total population. It is expected that by the year 2050, their number of will triple to 98 million, and that Hispanics will then constitute one-fourth of the U.S. population. Hispanics have the highest fertility rate of any U.S. ethnic group, growing at a pace that is three times faster than any other U.S. ethnic group. They also have the lowest divorce rate and the highest marriage rate of any ethnic group in the United States.
With a mean age of 26 years, Hispanics are the youngest ethnic group in the United States-almost a decade younger than the rest of the U.S. population (35.3 years). The largest subgroups by percentage of the U.S. population are Mexican Americans (65%), people of South American heritage (14%), Puerto Ricans (10%), people of Central American heritage (7%), and Cuban Americans (4%).
One out of every two Hispanic Americans was born in Latin America. The population of Latin America also grew to 500 million in the last decade (between 1990 and 2000) constituting 8.2% of the world population. Immigration from Latin America to the United States represented an important factor in the population growth of Hispanics in the United States. The largest number of immigrants in the last decade came from Mexico, Cuba, the Dominican Republic, and El Salvador (U.S. Census Bureau, 2003).
Less than 20% of the world population lives in wealthy countries, and the majority of Hispanics immigrate to the United States to escape poverty. Poverty is usually interrelated with war and political unrest. Because poverty is likely to continue to affect many Latin American countries into the twenty-first century, Latin American immigrants will probably continue to arrive in the United States in large numbers (Central Intelligence Agency, 2001).
THE IMMIGRANT EXPERIENCE
Immigration is one of the most stressful events a family can undergo. It removes the family members from many of their relationships: friends, neighbors, and members of the extended family (Suarez-Orozco and Suarez-Orozco, 2001). It also removes the family from their community, jobs, schools, customs, and sometimes language, placing them in a strange and unpredictable environment (Ticho, 1971). These changes are disorienting and inevitably lead to a sense of loss.
Immigration destabilizes the family in a variety of ways. Suarez-Orozco and Suarez-Orozco (2001) suggest that the journey of Hispanic immigrants to the United States is a highly fractured, phase specific process that results in psychologically complex patterns of family fragmentation and reunification. Children and adolescents are often left behind in the care of grandparents or other relatives and may not reunite with their parents for years to come. Immigrant parents sometimes have to make a Faustian bargain, gambling with the dream of having a better life at the risk of undermining family cohesion and their parental authority and the risk of losing their children to the new culture.
Types of Immigrants
Most Hispanics in the United States are financial immigrants who fled the poverty in Latin America and came to the United States in search of a better life. Smaller numbers arrive in search of discovery or knowledge, seeking to further their personal growth or looking for better professional opportunities. In all of these cases, the immigrant's journey contains the possibility of returning for visits. In doing so, the immigrant undergoes a process similar to refueling (Mahler, Pine, and Bergman, 1975), and after a short visit to the country of origin, returns to the United States fully reenergized and ready to take on the world (Akhtar, 1999). However, some immigrants leave their native country by force. This particular type of migration involves expulsion, banishment, or being cast out and is known as exile (a word that derives from the Greek "ex-Ilia," meaning "no longer Greece"). In ancient Greece, exile was considered a form of cruel and unusual punishment (Grinberg and Grinberg, 1989).
Still another type of immigrant is the refugee or asylum seeker, who is fleeing from a clear and present danger. This type of immigration is usually accompanied by varying degrees of psychological trauma, which may leave the immigrant and his or her family with psychological sequelae such as PTSD (Rothe, Castillo-Matos, and Busquests, 2002; Rothe, Lewis, et al., 2002). Finally, the sojourner, who moves periodically to and from and sometimes within a country, is representative of another category of immigrant (for example, migrant workers who follow the seasonal crops). This type of migration causes multiple interruptions and discontinuities in the lives of children and adolescents, especially as it pertains to schooling (Cornelius, 1986).
Children and adolescents rarely participate in the decision to migrate. They are usually uprooted from their human environment (friends, teachers, and extended family members) as well as their nonhuman environment (house, school, neighborhood, and toys). They may not have had time to even say good-bye to their friends and other significant figures in their lives and may leave their previous homes abruptly, without having been given much warning or explanation by their parents. So, in this sense, children and adolescents are always exiles (Grinberg and Grinberg, 1989). To this should be added that, aside from the stresses of migration affecting the adolescent, one should also take into account the stresses inherent in the particular stage of development (Bios, 1966). The parents of the adolescents are themselves usually overwhelmed by the stresses and mourning that accompanies the process of migration; consequently they may be emotionally unavailable and unable to recognize or to help their children negotiate their own intrapsychic process.
Case 1
Alicia, a 29-year-old South American professional woman, had migrated back and forth between South America and the United States throughout her childhood and adolescence as a result of her father's job with a multinational company. Alicia recalled the uncertainty and dislocation she experienced every time she arrived in a new city and had to adapt to the different customs, speech characteristics, and mode of dress of her school peers. "I had to start all over every single time. All of my childhood I was always the outsider, never feeling like I belonged." One day in therapy, Alicia reported that her mother had deeply hurt her by recalling a memory that they both shared, explaining, "My mother reminded me of the time when I was 13 years old and we had just arrived in the United States. I was very sad because I had left behind important friends and my three grandparents. She told me that on that night I got up at the dinner table and proclaimed in Spanish, 'Esta no es mi tierra' (This is not my land). My mother then added, 'You were so cute and so melodramatic.'" Alicia felt humiliated by her mother's comments and recalled sadly, "Even to this day, my parents have no idea how deeply all those moves affected me."
THE CULTURAL ENCOUNTER
DeVos (1980) and Ogbu (1978) describe three themes that have a determining effect on the adaptation and identity formation of the immigrant adolescent and his or her family.
1. Under what circumstances does the immigrant enter the host culture (voluntary migration versus forced migration, conqueror versus slave)?
2. Is there a structural ceiling (social hierarchy) above which the immigrant cannot rise, regardless of effort, talent, or achievement?
3. Is there a cultural ethos or stereotype that fits the immigrant, from which he or she cannot separate?
At times, a person who is regarded by the majority culture as a member of a particular ethnic group or who regards himself or herself as of a particular ethnicity may find his or her identity changed by the immigration process, such as in the following example.
Case 2
In my role as a psychiatric school consultant, I was asked by the school counselor to meet with a Hispanic mother that the staff was having trouble "getting across to" and whom they regarded as being "a little crazy." Mrs. M was the 52-year-old mother of an adolescent boy who attended middle school. According to the school counselor, Mrs. M visited the school several times a week and demanded that the teachers and the principal "do something about the mean kids that are bullying my son and causing him to be exposed to bad influences." Neither the teachers nor the principal saw her son, a very able and well-adapted 14-year-old, as exhibiting any particular difficulties, and they believed that her demands were unreasonable. On meeting Mrs. M, I realized that she did not speak English, so we began speaking in Spanish. However, I also noticed that she spoke Spanish with much difficulty and with an accent that I could not identify.
Mrs. M explained that she was a native of Peru and that her mother tongue was Quechua, a pre-Columbian language spoken by the Inca Indians in the Andean High Plain region of South America. She added that she had a third-grade education and was trained as a seamstress in a small rural town, from which she had immigrated briefly to Lima, Peru's capital city. There, she felt overwhelmed by big-city life and had difficulty finding work. In Lima, she met a boyfriend who enticed her to immigrate to Miami with him and her son, but the relationship had ended and the two were no longer together. Mrs. M complained to me that she felt "out of sorts" in Miami, even when surrounded by Hispanics, with whom she felt she had very little in common. She explained that she had been unable to connect with any compatriots who had a background similar to hers. She reported that her son was "practically running the household" and that she felt inept and threatened by what she believed was "a state of wild permissiveness in this country." Her thought process appeared quite concrete, and she used magical thinking to explain or understand her surroundings. For example, she demanded that the school authorities "change the behavior and attitude of all the students in the school" so that her son would "feel safe," a statement that the school counselor believed to be psychotic.
I began working with the school staff, trying to clarify that much of Mrs. M's behavior was a result of culture shock and that her mode of thinking could be understood as characteristic of a native South American person of rural extraction who was confused and perplexed by the lifestyle and customs of U.S. city life. The school staff and I also attempted to become more familiar with Mrs. M's cultural background, in order to be more effective in helping her and her son.
The Acculturation Process
Migration is today considered to be a transformative process in which the immigrant adds new elements to his or her identity that belong to the new culture and deletes elements from the old culture that are no longer useful. This is different from the classic studies in anthropology and the social sciences, which proposed that for immigrants arriving in the United States, the most effective and healthy way to become a part of the new culture was to assimilate. In the assimilation model, the person renounces his or her culture of origin and identifies and accepts the culture of the host country. This model applied well to immigrants arriving from Europe in the 19th century and well into the 20th century. Most of these immigrants had similar ethnic characteristics and often Americanized their names, going on to become part of the melting pot. However, the current U.S. mass media present images of a middle-class Anglo American culture that are untenable to many members of minority groups and immigrants, especially if the individual is of color. Even those who achieve competence in the dominant culture often experience a sense of loss that threatens their personal identity. For instance, television images generally portray a blond, blue eyed adolescent girl who represents the American physical ideal. This image is very different from the physical characteristics of a brown-skinned Mexican American adolescent girl of mixed (Spanish European and Native American) ethnicity. In such cases, the minority adolescent may find it difficult to identify with the cultural ideal being portrayed by the majority culture (Rogler, Cortes, and Malgady, 1991).
Marginalization. Marginalization is another form of acculturation, in which the immigrant embraces the culture of the country of origin, while residing in the host country. These individuals often stand in defiance against the culture of the host country and inhabit ethnic ghettos in which the language and the customs of the country of origin are preserved. Marginalization is a common form of adaptation among exiles, especially those who immigrate when they are adults. These individuals consider that it's too late to start all over again. This cultural dislocation and marginality intensifies when there are sharp ethnic contrasts between the two cultures.
Marginalization of the parents represents a problematic situation for their adolescent children, who are encouraged by the parents to remain in the ethnic ghetto. Departure from it is sometimes regarded as a betrayal of the parents' cultural and traditional values.
Studies conducted by Szapocznik, Ladner, and Scopetta (1979) and Szapocznik and Kurtines (1980) with well-acculturated Cuban American adolescents who spoke little Spanish and lived with poorly acculturated Cuban parents who spoke little English, found severe forms of conduct-disordered behavior and substance abuse in the adolescents. These investigators speculated that the adolescents in question felt alienated from their parents and were not able to fully integrate into the adolescent peer group of the host culture. This led them to identify, instead, with similarly marginalized adolescents who were at risk for developing depression, substance abuse, and conduct disorders.
In the traditional family, the parents are expected to guide the children through the complexities of life. In the process of migration, this role is often reversed. If the immigrant parent is unable to speak the new language, he is demoted to the level of a two-year-old (Grinberg and Grinberg, 1989) and profound narcissistic injuries and depression may follow. These effects may also become reflected in the adolescent, whose parents are unable to provide a strong and consistent holding environment necessary for the successful completion of the adolescent process.
Continued from page 2.
Identity transformation. Acculturation also involves a transformation of the immigrant's identity, which will be closely related to the individual's ethnic identity. Children's awareness of ethnic identity and the awareness of ethnic and cultural differences appear for the first time by the age of three or four. Children also begin noticing differences of language utilization by this age. Between the ages of four and eight, children develop an ethnic orientation; they select one social group over another; they consolidate a sense of group concept; and they develop curiosity about other groups (Porter, 1971). Also at about this age, children become keenly aware of their reception by others. Discrimination may appear when moving from a minority community to a nonminority community, but it may also appear while moving within minority communities, such as in the following example.
Case 3
Carmen, a 17-year-old mulatto adolescent girl, was referred for a psychiatric evaluation because she wore sexually provocative clothes to school and because of her sexually provocative behavior toward adolescent boys, which was causing great turmoil in the classroom. Carmen was born in New York City to Puerto Rican parents and until moving to Miami the year before had always thought of herself as Hispanic American and Puerto Rican. On interviewing her, I discovered that her problems were largely a result of feeling rejected by her predominantly white, Cuban American female peers: "They don't accept me because I'm too dark," she confessed with deeply felt pain and anger. Her accent in English appeared to be an exaggerated attempt to identify with African American inner-city youth who validated her racial identity. Her sexually provocative behavior, on the other hand, appeared to be an effort to gain the attention of the male adolescents in the class, and as a reparative attempt against the pain of rejection and narcissistic injury that she was suffering as a result.
If the adolescent feels that he or she is unable to accomplish social integration or feels rejected by the mainstream culture, or if his or her particular ethnic group is viewed by the majority culture as devalued and denigrated, the Hispanic adolescent may identify and internalize these negative perceptions, which may lead to ethnic self-hate (Vega, Hough, and Romero, 1983). The Hispanic adolescent may respond with passivity and depression, which in turn may lead to substance abuse. Or, on the opposite end of the continuum, the adolescent may develop an adversarial identity, standing in defiance of the majority culture, which is seen as depriving the adolescent of social and financial aspirations and marginalizing him or her. The adolescent then becomes, in the words of sociologist Alejandro Portes (1996), "a part of the present urban pathologies" (p. 53). Some of these adolescents, who are not able to embrace their own culture and who develop an adversarial identity against the mainstream culture, may join gangs. For these adolescents, gangs offer a sense of belonging, solidarity, protection, discipline, and warmth. Gangs also "structure the anger many feel towards the society that violently rejected their parents and themselves" (Suarez-Orozco and Suarez-Orozco, 2001, p. 108).
Vigil (1988) studied Mexican gangs in southern California and found that many adolescent gang members come from urban poverty and limited economic opportunity and are members of a racially unmeltable ethnic minority that has suffered discrimination. He also reports that these adolescents often come from troubled backgrounds, with abusive or unavailable parents and homes with abundant substance abuse. They also lack available strong adult figures who could take the place of parents and help the youth navigate the tensions of adolescence. Some of these adolescents manage to outgrow the gang mystique after working through the identity issues of adolescence. For these adolescents, the gang serves to provide a sense of identity and cohesion during a turbulent stage of development.
Biculturalism. Assimilation and marginalization represent opposite ends of the acculturation spectrum. However, in the United States today, a new model of acculturation has been proposed. Biculturalism allows for the validation and reaffirmation of the person's identity by both the old and the new culture, allowing for the person to consolidate his or her sense of self. In becoming bicultural, the Hispanic adolescent "must creatively fuse elements of both cultures-the parental and the new culture in a process of transculturation that blends two systems that are at once their own and foreign" (Suarez-Orozco and SuarezOrozco, 2001, p. 47). This new construct of the self validates the authority and legitimacy of the parents' culture and traditional values, without compromising the Hispanic adolescent's newly acquired language and cultural competencies in the U.S. mainstream culture. Rather than shamefully wishing to distance themselves from their parents, these adolescents come to experience success as payback for their parents' sacrifices. For these adolescents, the experience of success, making it or becoming somebody, becomes a culturally syntonic experience that, rather than alienating them from their ethnic community, is perceived as a form of giving back and making the community proud of their success. It also gives them a sense of purpose that serves as a protective factor against the problems associated with alienation and marginalization, such as substance abuse disorders.
HISPANIC ADOLESCENT REFUGEES
In the last three decades, war, famine, and political struggles have caused an increase in forced migrations worldwide. In 1970, the number of refugees worldwide was 2.5 million. In the year 2000, the number has grown almost sevenfold to 17 million, or one out of every 135 people alive (Human Rights Watch, 2003).
The refugee experience is often characterized by a catastrophic uprooting, with suddenness, lack of preparation, and arrival to the sheltering country under chaotic circumstances, all of which are likely to compound the feelings of loss and dislocation experienced by the refugee.
Many of the refugees arriving in the United States today are adolescents from Latin America. Arroyo and Eth (1985) were the first to bring attention to the problem of Hispanic refugee children arriving in the United States fleeing civil wars in Central America. These investigators reported serious acting-out behavior in adolescent refugees who had been previously exposed to civil war atrocities. Among these behaviors were serious aggression, out-of-wedlock pregnancies, substance abuse, and psychosis. The premorbid histories of these children and adolescents often included profound poverty, domestic violence, and separation from the parents, who had immigrated first to the United States.
Case 4
Cesar Auguste, a 14-year-old refugee adolescent boy from El Salvador, was referred for psychiatric treatment after he had sexually molested the son and daughter of the U.S. family who had sponsored his entry into the United States. Cesar Augusta's father had been murdered by the Salvadorean army for belonging to a left-wing guerrilla group, and his mother had been imprisoned and tortured due to her own political activism. Thanks to the efforts of a Protestant religious group in Boston, his mother was released and arrived in the United States five years before Cesar Augusto, leaving him in the care of extended family back in El Salvador. Cesar Augusto presented as an aloof, distracted boy who was difficult to engage in therapy and spent a considerable amount of time daydreaming. He would often forget appointments and would wander off on his bicycle with no particular destination.
Cesar Augusto met diagnostic criteria for posttraumatic stress disorder (PTSD), with a predominance of symptoms of avoidance and reexperiencing of the traumatic events. One day, as I was sitting with him on the steps of the clinic while he waited for his mother to pick him up, we saw a man walking his dog. Cesar Augusto became pensive and then shared a personal memory with me: "I used to have a dog in El Salvador. One day gunfire broke out in the street outside our house. My aunt began screaming frantically, telling me to throw myself on the floor. In the middle of the screaming, my dog got scared and started running into the street where the shooting was taking place. Suddenly, I saw my dog topple over and lie still, but I couldn't get to him because the shooting was still going on. When the gunfire finally stopped, I went outside and called him several times, but he didn't move, so I lifted him, then I noticed that he had a small hole on the side of his head where the shot went in, and his brains were all splattered on the other side."
As the treatment progressed, I learned that Cesar Augusto was constantly haunted by other similarly traumatic memories. I was never able to elicit any history of sexual victimization from him, and the reasons why he became a sexual perpetrator were never fully clarified. However, I suspected that his psychological victimization during the war could have contributed to the development of identification with the aggressor and repetition compulsion, defenses against the helplessness and war trauma he experienced. Sexualization of these defenses could help to explain his role as a sexual perpetrator.
Rothe, Castillo-Matos, et al. (2002) described elevated rates of PTSD in Cuban adolescents who survived a perilous ocean crossing and were later subjected to prolonged confinement in refugee camps prior to entering the United States. Contrary to the findings of Arroyo and Eth (1985) on adolescent victims of a civil war, including increased aggression and acting-out behaviors in these adolescents, Rothe, Lewis, et al. (2002), who studied Cuban children and adolescent refugees after arrival in the United States, reported that the majority of them continued to experience symptoms of PTSD after arriving in the United States. Their predominant symptoms, however, fell into the avoidance and reexperiencing cluster of symptoms described in the DSM-IV (APA, 1994) diagnostic criteria for PTSD. As a consequence, the symptoms were experienced subjectively, were not noticed by their teachers, and did not appear to affect their school functioning. These findings parallel those of other investigators who studied Vietnamese, Cambodian, Bosnian, and Tibetan adolescent refugee victims of war (Jensen and Shaw, 1993). The long-term significance of these findings remains to be determined.
There are other migratory routes taken by Hispanics as they enter the United States that are equally as traumatic as those taken by refugees. For example, the journey across the Mexican border that many Mexican and Central American families endure to enter the United States illegally is replete with danger and trauma. The stress of these immigrants is compounded by the fact that they are undocumented and under threat of being deported by the U.S. authorities. The traumatic effects of war and its derivatives may also severely affect the families of adolescent refugees, regardless of their legal standing as immigrants, such as in the following example.
Case 5
A 49-year-old Colombian woman was seen in therapy due to symptoms of anxiety and PTSD, which resulted after her 19-year-old daughter was kidnapped by a guerrilla organization in Colombia. The daughter was eventually released after one year in captivity and after Mrs. R's husband paid a large ransom, which left the family financially bankrupt. The entire family, which included the parents and three other children, fled to Miami immediately after the daughter was released. Mrs. R explained to me, "There must be something strange happening to me. We've been in Miami for almost two years already, yet I find that I'm unable to experience anger toward my daughter's kidnappers. I feel that if I do, they could somehow still kill her, even though I practically have her next to me at all times."
Identifying the psychiatric symptoms of traumatic migrations presents a diagnostic challenge to clinicians involved in the treatment of refugee populations, because many of these symptoms are experienced subjectively and are silent. A comprehensive background history, including details about the circumstances surrounding the migration, should always be a part of the psychiatric evaluation of the refugee adolescent and his or her family.
THE STRUCTURE AND CUSTOMS OF THE HISPANIC FAMILY
In the process of immigrating to the United States, the Hispanic family has undergone dramatic structural changes. The traditional extendedfamily network system in which parents, grandparents, and grandchildren live in close proximity and the husband sits at the top of the hierarchy, with the wife serving a surrogate role, has changed due to the financial demands of moving to an industrialized society. In the United States, many Hispanic mothers now work and earn salaries comparable to those of their husbands, which is often seen as undermining the male's authority in the family. Children are more often left unsupervised.
A study by Pumariega and colleagues (1992) examined 5,000 Mexican and Mexican American high school students in five similar cities on each side of the Rio Grande Valley along the U.S.-Mexican border. They reported less substance abuse and risk of psychiatric psychopathology in the adolescents on the Mexican side of the border, in spite of the fact that adolescents on both sides had similar accessibility to drugs and more poverty existed in Mexico. The study revealed that the adolescents on the U.S. side spent more time unsupervised by adults, had less access to adult members of the extended family, spent more time watching television, and relied more on the peer group than on adults for company and support.
Hispanic boys are often allowed more freedom than Hispanic girls, who tend to stay closer to the family. Paradoxically, this has allowed Hispanic girls to outperform Hispanic boys academically and to be more protected from the risk of substance abuse. Hispanic girls view school as a time of relative freedom, which allows them to socialize and to experience emotional growth away from the close vigilance of the family (Suarez-Orozco and Suarez-Orozco, 2001); thus school attendance is important to them.
Hispanic male adolescents learn to be more assertive as they acculturate into the U.S. mainstream. This assertiveness often clashes with the values of respect (Canino and Spurlock, 1994) and self-effacement expected by the traditional Hispanic culture from members of the younger generations. Many Hispanic families in the United States deal with the problem of unruly behavior in their children by sending them back to Latin America, "where they will learn respect." Dominican adolescents living in New York City are often sent to schools back on the island, where discipline and respect are strongly enforced. As a Dominican school principal explained, "Sometimes we choose not to have more than two 'Dominican-Yorks' [children of Dominican parents raised in New York City] in a classroom, because more than two of them can turn your classroom upside down."
Case 6
Irma Maria, a 16-year-old adolescent girl from Guatemala, was referred to therapy by the state social services agency after she accused her stepfather of sexually molesting her. The stepfather had been evicted from the home while the investigation took place. As part of the evaluation, I met with Irma Maria's mother, who vehemently denied her daughter's sexual abuse allegations, saying, "She is totally out of control. The only reason she made those accusations is that my husband has been trying to set limits on her. She wants to do whatever she wants, and we will not put up with it." A few weeks later, after her daughter had missed the last appointment, Irma Maria's mother came to the clinic alone and explained, "I came here to apologize and to tell you that the problem is already taken care of. I took my daughter to Guatemala on a visit. I didn't tell her anything, and I left her there with my parents; she won't be coming back. They will be able to straighten her out over there, because people don't put up with her kind of behavior in our country. Now I have my husband back living with me at home and all is well."
In essence, the Hispanic family is based on a triad of values that it shares with other cultures of Mediterranean origin, namely (1) respect, (2) affection, and (3) dignity. Hispanic youth are taught to respect others at all times, always maintaining the intergenerational line and addressing anyone older than themselves with "usted" (the formal "you"). Hispanic youth are also taught to express affection openly in all human interactions, to maintain personal dignity, and to guard the family dignity with zeal. This triad of respect, affection, and dignity has been very useful in helping to maintain family cohesiveness and a positive self-image, and it serves as a protective factor to the Hispanic immigrant against the stresses of migration and acculturation into the new country (Ruiz and Langrod, 1997).
POVERTY AND OTHER STRESSORS
Most Hispanics who immigrate to the United States to escape poverty tend to be low-skilled workers from the rural areas of Latin America. These immigrants are semiliterate in their own languages and end up holding low-paying jobs that do not hold much promise of upward mobility. Many end up living in crime-infested, low-rent urban areas, in environments that are increasingly segregated from whites. These Hispanic immigrants place all of their hopes on their children, praying that the next generation will become a part of the American dream. In the meanwhile, however, the families have to survive living in overcrowded buildings with very little space and limited privacy. Their neighborhoods are unsafe, and children and families live in an atmosphere of impending danger and risk of vice that undermines social cohesion and creates social disadvantage (Canino and Spurlock, 1994; Suarez-Orozco and Suarez-Orozco, 2001).
Inner-city schools are usually overcrowded and understaffed and offer an inferior level of education, when compared with suburban schools. The cycle of poverty, coupled with inferior levels of education, threatens to create a downward spiral of declining financial opportunity from which the Hispanic immigrant cannot escape (Orfield and Yun, 1999), generating what anthropologist Oscar Lewis (1966) has called the culture of poverty. The child and adolescent psychiatry literature supports the fact that poverty alone is not sufficient to cause problems in development (Canino and Spurlock, 1994). Factors such as family discord and disruption of attachment appear to have a stronger impact on the development of mental health problems in children and adolescents.
On a more optimistic note, the last decade witnessed a rise in income and a decline in poverty for Hispanic Americans (U.S. Census Bureau, 2002). Hispanics are relatively well integrated into the U.S. social fabric, yet many still choose to live in the ethnic enclaves of cities such as San Antonio, Miami, Los Angeles, and New York. These function as completely bicultural communities in which language and traditions can be maintained and passed from one generation to another, allowing for a sense of continuity and integrity in the immigrant's cultural identity.
THE HISPANIC ADOLESCENT IN THE SCHOOL
Landale and Oropesa (1995) have found that "adaptation to school is a significant predictor of the child's future well being and contributions to society" (p. 3). The 2000 census revealed that more Hispanics graduated from high school in the last decade of the 20th century than in the previous one. However, the number of Hispanic college graduates remained alarmingly low. Only 11% of Hispanics had bachelor's degrees, and an even smaller number had graduate degrees. Unfortunately, male and female Hispanic adolescents had the highest dropout rate in the country. The dropout rate for Hispanic adolescent girls was 26%, compared with 13% for African Americans and 6.9% for white adolescent girls. Hispanic adolescent boys had the highest dropout rate of all groups, reaching 31%, compared with 12.1% for African Americans and 7.7% for white male adolescents.
The causes for dropping out of school are multiple and complex. Among Hispanic girls, conflicting traditional values such as aspiring to be wives and mothers sometimes take precedence over values that are more representative of a society in which women work alongside men to support their households, and where women are allowed to have the same professional aspirations as men. Many Hispanic adolescent girls drop out of school to become mothers at a very young age, leaving them vulnerable and without job skills if they lose the support of the spouse.
Immigrants usually enter the host culture at the bottom of the socioeconomic ladder, forcing Hispanic adolescents to prematurely assume adult social roles, abandoning school to help support the family. Also, many newly arrived Hispanic children and adolescents enter the school system with limited English proficiency and are unable to compete effectively against native English speakers. Because complex socioeconomic variables are at play, school programs collectively known as English for speakers of other languages (ESOL) have proved to be insufficient in decreasing the rate of Hispanic school dropouts.
Rumbaut (1995) has described a negative association between the immigrant's length of residence in the United States and his or her grade-point average and academic and professional aspirations. As the new immigrant family arrives, the parents' sacrifices and encouragement to succeed push forward the first generation of immigrant children. However, after some time in the United States, the second generation moves further away from the culture of origin and is caught in a noman's-land, unable to identify with the models of either culture.
Suarez-Orozco and Suarez-Orozco (2001) highlight the importance of language for the Hispanic immigrant, and pointing out that bilingualism (which in the past was regarded as an obstacle to assimilation and a cognitive disadvantage) is now regarded as the opposite. Higher degrees of bilingualism appear to be related to higher cognitive attainment (Hakuta and Garcia, 1989). Yet children who are in the process of learning a second language are usually overrepresented in learningdisabled classes, and linguistic problems represent one of the most frequent reasons for psychiatric school referrals. Difficulty with verbal expression frequently results in frustration and acting-out behaviors in these students. However, the issue of bilingualism is rarely considered as a causal factor (Canino and Spurlock, 1994). Language, in any case, remains strongly related to identity, as is evident in the following case.
Case 7
Victor, a 13-year-old Puerto Rican adolescent from a working-class family, was abruptly uprooted from his home when he and his mother moved to Boston from Puerto Rico following a marital dispute involving infidelity committed by Victor's father. In Boston, Victor became aggressive and joined a small gang of Puerto Rican youth, all of whom were struggling to fit in a multicultural, inner-city public school. Although the gang served to validate Victor's fragile sense of ethnic identity, his feelings of marginalization were aggravated by his poor command of the English language. One day Victor, who spoke in the colloquial slang characteristic of working-class Puerto Ricans, complained to me in therapy that he felt deeply humiliated and equally angry because "Mrs. McDonald, my Spanish teacher, corrected my Spanish and said I did not speak the language correctly." Indignantly, he added, "Who does she think she is? It's not even her own language!"
PHYSICAL HEALTH OF HISPANIC ADOLESCENTS AND THEIR FAMILIES
Barriers to Care
Lack of access to medical care and preventive health care represents a serious problem for the Hispanic population in the United States. Hispanic Americans constitute the largest percentage of uninsured in the U.S. population today (U.S. Census Bureau, 2002). More than 34.4% of Hispanic Americans have no medical insurance, compared with 21.6% of African Americans and 16% white non-Hispanics. These percentages of citizens with no medical insurance are echoed with respect to children and adolescents: 33.4% Hispanic, 21.2% African American, and 14.2% white non-Hispanic children and adolescents have no medical insurance.
Lack of medical insurance, of course, affects the access of Hispanics to mental health services. But Hispanics in the United States also underutilize health services due to barriers of culture and language. One result is that health problems such as obesity, diabetes mellitus Type II, and hypertension, which present a serious health risk, are endemic in the Hispanic population (Perez-Estable and NapolesSpringer, 2001). Hispanic Americans have the highest rates of diabetes of all ethnic groups in the United States. They receive fewer fundoscopic eye exams, blood sugar examinations, and other preventive examinations to screen for this condition; 24% of Mexicans, 40% of Puerto Ricans and 58% of Cubans did not know they had diabetes at the time of detection. Rates of obesity are also higher among Hispanic Americans, including children and adolescents, than among other ethnic groups. In Hispanic adolescents, 15.8% of girls and 14.8% of boys are obese (the percentages are 11.9% and 11.8%, respectively, for white non-Hispanic youngsters). Higher levels of acculturation are related to increased risk for obesity in Hispanic women.
A negative correlation between higher levels of acculturation and physical health among Hispanics appears to exist, and this counterintuitive finding, although not fully understood, appears to be related to increased stress, alienation, and marginalization, as the immigrant moves further away from his ethnic group but is unable to completely integrate into the new culture. Community clinics that serve the Hispanic population need to equipped by a culturally sensitive staff, with Spanish-speaking therapists offering a multiplicity of services and located near available public transportation. Education regarding dietary habits should be provided. Efforts should be made at developing culturally sensitive research employing ethnographic methodology and instrumentation that can help to conceptualize the research paradigm for the Hispanic population, such that research findings can then be used to improve treatment interventions.
SUBSTANCE ABUSE AND HIV INFECTIONS AMONG HISPANIC ADOLESCENTS AND THEIR FAMILIES
Hispanic Americans have the youngest mean age of any ethnic group in the United States. This, along with other variables, puts them at a higher risk for substance abuse than any other ethnic group. Alvarez (2001) summarizes these findings as follows:
1. Hispanic male adolescents have the highest lifetime and permonth use of alcohol.
2. Hispanic eighth-graders have the highest rate of use of most psychoactive drugs, including tobacco, as well as the highest rate of binge drinking.
3. Hispanic students are more than twice as likely to have used cocaine in their lifetime than any other ethnic group in the United States.
4. Hispanics have the highest rate of accidental drug-related deaths.
5. Hispanics and African Americans tend to underreport substance abuse.
6. The use of marijuana has also increased in certain Hispanic subgroups. Use of marijuana hampers knowledge acquisition and may also contribute to the fact that Hispanics have the highest school dropout rate in the United States. Also, marijuana can be the entry point for future use of stronger drugs.
Alvarez (2001), in a review of the literature of substance abuse among Hispanics, explains that Hispanic adolescents may be at higher risk for emotional distress because of increasing poverty levels, economic insecurity, experiences of inequality, and discrimination. This may account for the fact that Hispanic adolescents attempt suicide more often than any other ethnic group, and use of alcohol and other drugs is a high predictor of attempted suicide in this population. Hispanics are also significantly less informed about the negative effects of alcohol, tobacco, and drug abuse than other ethnic groups (Ruiz and Langrod, 1997), and the availability of drugs and alcohol to Hispanic adolescents increases in the inner city.
Cultural factors also play a role in substance abuse in this population. Machismo fosters the denial of substance abuse problems for fear of being perceived as weak, and the belief that it is a desirable male quality to be able to outdrink your rival. Hispanic families tend to be liberal about their view of alcohol, which is used commonly during social occasions. The extended family network system plays a more important role in the Hispanic culture than in cultures that value independence and self-reliance. If the tie to the family is disrupted, this can also put Hispanic youth at risk for substance abuse.
Hispanics have the highest rates of HIV infection of all ethnic groups in the United States. The National Center for Health Statistics (2000) data reflect that, among Hispanic men, 39% of reported cases resulted from homosexual contact, whereas 33.5% resulted from intravenous drug abuse (IVDA). In Hispanic women, 42.5% of reported cases of HIV resulted from IVDA, and 38.9% resulted from heterosexual contact. A vicious cycle results with regard to HIV transmission among the Hispanic population in the United States, in that poverty and social marginalization often lead to substance abuse, which in turn leads to risky sexual behaviors, increasing the risk of transmission of the HIV virus. Hispanic adolescent homosexual males are also at an increased risk for HIV infection. In the Hispanic culture, the values of machismo, which strongly reject homosexual behavior, may cause Hispanic homosexual adolescents to feel socially rejected and marginalized, setting in motion the vicious cycle of substance abuse, which also increases the risk of HIV transmission in this population (Rothe and Ruiz, 2001).
TREATMENT CONSIDERATIONS
Psychiatrists who treat Hispanic adolescent immigrants may be presented with a multiplicity of roles in the therapeutic relationship. Not only will they play a role as therapist to the adolescent, but they may also find themselves educating and treating the family for the psychological effects that result as a consequence of the migration. Sometimes the parents, overwhelmed by their own stresses, may benefit from help from the psychiatrist or may need to be referred to other mental health professionals.
Anticipating Transference and Countertransference
In the treatment of the Hispanic adolescent and his or her family, and especially when a cross-cultural patient-therapist dyad exists, the clinician must begin by analyzing the transference and countertransference. Cultural biases are more often bidirectional and negative and are colored by prejudice and stereotyping. If biases are not identified and confronted by the therapist and patient at the onset of treatment, this may generate a cultural distancing between patient and therapist, which, in turn leads to the development of distancing defense mechanisms in both the patient and the therapist. For example, Hispanic patients who come from countries with repressive totalitarian governments may initially exhibit considerable difficulty in trusting the therapist, who may be perceived as an authority figure allied to the larger and persecutory power structure.
Clinicians should also assess the socioeconomic and educational level of the Hispanic adolescent and his or her family, as well as their level of acculturation into the U.S. culture, because these variables are responsible for variations in belief systems and value orientations and will determine, to an important extent, the way the particular therapeutic approaches and therapeutic goals are structured. Failure to take these variables into account may lead to erroneous cultural oversimplifications and stereotyping that will damage the therapeutic alliance. For example, Canino and Spurlock (1994) recommend that the therapist always ask the adolescent and/or the family about their country of origin, and that the therapist make an effort to become familiar with the national or cultural characteristics of the country in question. In addition to enhancing awareness of the patient's identity by making such efforts, the therapist demonstrates respect for the patient's individuality, facilitating the therapeutic alliance.
It is also important to pay attention to the existence of power differentials in the therapeutic dyad. Most commonly, with the Hispanic adolescent and his or her family, it is the therapist who will be at risk of feeling consciously or unconsciously superior to the patient, which may affect the countertransference and hamper the treatment by leading to feelings of sympathy, rather than empathy, toward the patient.
Many Hispanic patients (especially newly arrived immigrants) have never encountered a mental health professional. Accordingly, the therapist should ask questions about how the patient understands the therapeutic encounter, encouraging questions about the therapeutic process. A willingness to explain and clarify the process will help the patient understand the goals and expectations of the therapeutic work.
Assessing Risk Factors and Resiliency
In the initial interviews, it is important to assess the risk factors and protective factors affecting the Hispanic adolescent and his or her family. Because poverty, in itself, does not necessarily compromise resiliency or promote psychopathology, the therapist should become familiar with the individual, family, and community factors that promote resiliency in the adolescent and compensate for risk. For example, in the traditional culture, Hispanic families place great importance on the extended family network system, which may provide protection, supervision, love, and support to the adolescent in times of crisis. In helping to promote family cohesion and family strength, the therapist is also helping to develop resiliency and strengths in the adolescent.
Continued from page 6.
The school constitutes another cornerstone in the life of the Hispanic adolescent. The therapist can be instrumental in helping school authorities with the accurate placement of the Hispanic adolescent, clarifying cultural distortions and barriers related to social class and immigration. Placement in the wrong classroom category may lead to academic failure, demoralization, and abandonment of school. The school is also the most appropriate place to provide the Hispanic adolescent with preventive health and mental health education, teaching adolescents about the risks associated with substance abuse and HIV transmission by clarifying and dispelling distortions associated with the values of machismo, which glorifies tobacco, alcohol abuse and male promiscuity. The completion of a formal education represents the hopes and aspirations of many Hispanic adolescents and their parents, who made significant sacrifices for the promise of a better future for their children. It is important to become familiar and, if possible, involved with programs that aim to reduce and prevent school dropout rates in this population.
The Doctor-Patient Relationship
Traditionally, Hispanics regard their doctors as authority figures; they develop a linear, hierarchical relationship in which the doctor is expected to give clear directions and the patient is rewarded by praise from the doctor when these directions are followed. This traditional value system can prove to be problematic when treating adolescents, because it can amplify developmental issues associated with individuation from the parents and identity formation in the adolescent patient. The therapist should be aware of these countertransference reactions, especially since, in the Hispanic culture, giving assent is considered a sign of respect toward anyone older than oneself, even when the individual is in disagreement with the issue in question.
The traditional Hispanic value of "personalismo" explains why Hispanics develop affiliations with individuals rather than with institutions. Once trust in the doctor has been established, Hispanics will rarely, if ever, question the doctor's professional pedigree or qualifications. The Hispanic family is more concerned with finding "a doctor who cares." The open expression of emotions, which involve greeting the doctor by hugging and "kissing in the cheek" and bringing presents for Christmas and other holidays are considered a matter of course. The therapist who resists these exchanges may run the risk of being perceived as cold, aloof, and uncaring and may hurt the family feelings or pride. Once the doctor is awarded the family trust (confianza), he or she may be consulted for a variety of life situations affecting the family and will be regarded as a wise counselor and considered a member of the family's trusted inner circle.
Effective Treatment Approaches
Short-term, time-limited psychotherapy has proved to be the most effective approach to treatment with traditional Hispanic adolescents and their families. The therapy should be present-oriented and address the here and now of the situation. On the first visit, the therapist should delineate clearly identifiable problems and measurable goals; these should be reassessed with every therapeutic visit and should focus on the immediate relief of symptoms. Traditionally, Hispanics are not interested in and are unfamiliar with long-term therapies for the purpose of personal growth. If the goals of the therapy are not clearly delineated from the start, the therapist runs the risk of the patient's becoming confused or disillusioned with the therapeutic process, and dropping out. Cultural nuances, such as being late and the use of somatization to express emotional distress, are common in the Hispanic population and should be analyzed within their cultural context.
Traditionally, Hispanics rely on an extended family network system. Excluding important family members, such as grandmothers, from the treatment process may sometimes result in a sabotage of the therapy by the excluded members. Szapocznik et al. (1988) have successfully used a combination of structural and strategic family therapy in the treatment of Hispanic families. This therapeutic approach aims to restore the traditional family hierarchy, which promotes equilibrium and resiliency and is culturally syntonic with traditional Hispanic family values. It is always important to remember that, in contrast to AngloSaxons, Hispanics do not necessarily aspire to become independent and self reliant. Instead, they prefer to stay closely connected to their families and to get along better with them.
Treatment Goals
In treating the newly immigrated Hispanic adolescent and his family the therapist should strive to
1. provide a holding environment, a safe place where the immigrant Hispanic adolescent patient can express his or her affects freely and experience containment and tolerance.
2. facilitate the mourning process of the Hispanic immigrant adolescent, who has left behind loved ones in the country of origin and is not permitted to express sorrow within the family unit for fear of appearing ungrateful about the family sacrifices (the therapist will be able to provide safety in the period of disorganization and decathexis).
3. become an object of identification with whom the adolescent can rehearse the newly acquired parts of his or her identity belonging to the new culture; the therapist should also strive to help the adolescent delete the parts of his or her identity that are no longer useful.
4. become a self-object and a love-object, to the adolescent in the context of the transference, utilizing the therapy as a reconstructive emotional experience.
5. serve as a mediator of affects between the adolescent and his or her family, allowing both to complete the process of adaptation to the new culture.
6. serve as a mediator between the adolescent's family and the new culture, empowering the family, promoting their autonomy, and enabling them to create a new milieu in which to thrive.
REFERENCES
Akhtar, S. (1999), Immigration and Identity: Turmoil, Treatment and Transformation. Northvale, NJ: Jason Aronson.
Alvarez, L. R. (2001), Substance Abuse in the Hispanic Population. In: The Latino Psychiatric Patient: Assessment and Treatment, ed. A. G. Lopex & E. Carrillo. Washington, DC: American Psychiatric Press, pp. 193-18.
American Psychiatric Association (1994), Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: American Psychiatric Press.
Arce, A. A. (1993), Transference issues in cross-cultural therapy. Simon Bolivar Award Lecture. Presented at Annual Meeting of the American Psychiatric Association, May, San Francisco, CA.
Arroyo, W. & Eth, S. (1985), Children traumatized by Central American warfare. In: Post-Traumatic Stress Disorder in Children, ed. S. Eth & R. S. Pynoos. Washington, DC: American Psychiatric Press.
Blos, P. (1966), On Adolescence: A Psychoanalytic Interpretation. New York: Free Press.
Canino, I. A. & Spurlock, J. (1994), Culturally Diverse Children and Adolescents: Assessment, Diagnosis, and Treatment. New York: Guilford.
Central Intelligence Agency (2001), Report on Latin America. In: The World Fact Book 2003. Central Intelligence Agency, Office of Public Affairs, Washington, D.C. 20505. Available at http://www.cia.gov/ cia/publications/factbook/index.html (accessed January 1, 2004).
Cornelius, W. A. (1986), From Sojourners to Settlers: The Changing Profile of Mexican Migration to the United States. Stanford, CA: The Americas Project. Stanford University.
De Vos, G. (1980), Ethnic adaptation and minority status. /. CrossCultural P sychol, 11:101-112.
Grinberg, L. & Grinberg, R. (1989), Psychoanalytic Perspectives on
