Adjustment Disorder: Intergenerational Conflict in a Chinese Immigrant Family

Clinical history

A. Patient identification

Mr. K. is a 55 year-old immigrant from Taiwan who presented to the mental health clinic of an Asian-specific community health center in February 1997. Accompanied by his wife and daughter, Mr. K was seeking family therapy following his arrest for assaulting his daughter after a family argument. Mr. K. is of average height for a Chinese male and is stocky but not muscular. His dress, in slightly stained blue jeans and a casual shirt, indicates his working class position as an employee at a car service center. When he begins to speak however, his vocabulary and locution reveal him to be an educated and refined man. His hair is mostly gray, which makes him look older than his 55 years, and he wears an earnest and humble expression.

B. History of present illness

According to his family, Mr. K. had no previous history of psychiatric illness or physical aggression prior to the incident with his youngest daughter. Mr. K. reported that he is frustrated and unhappy in his low-status job; nevertheless he works hard and functions adequately at work. Beyond his legitimate financial and legal concerns, he exhibits an inflexible and ruminative cognitive style but does not endorse any other mood or neurovegetative symptoms. Mrs. K. is a 43 year-old immigrant who moved with Mr. K. to the U.S. in 1989. Mrs. K. appears to be an ambitious woman who is willing to take the necessary steps to pursue the American dream. She works as a nursing assistant and does part-time hospice care for the elderly. At the same time she is preparing for board examinations to be credentialed to work as a nurse in the U.S. Mrs. K. reportedly feels constantly pressed for time, suffers from chronic sleep deprivation, and complains of frequent fatigue and irritability. Nevertheless, she maintains that she is spirited and hopeful about improving her and her family’s lives in the U.S.

Approximately four months earlier, J.K., Mr. and Mrs. K.’s 23 year-old daughter, moved back home after graduating from a local public university. Since that time there had been escalating conflicts between Mrs. K. and J.K. J.K. complained that her mother was critical and controlling about such things as her style of dress, the way that she cooked, the things that she ate, and the way that she drove. According to Mrs. K., J.K. was confrontational, loud and disrespectful. While Mr. K. usually did not get involved in their arguments, on the day of the incident he was angered by J.K.’s rudeness to her mother and slapped her in the face. Attempting to dodge Mr. K.’s hand, J.K. reportedly bumped her head against the door and bruised her face.

In a state of anger and disbelief, J.K. called the police. Mr. K. was arrested and detained in police custody for two days. J.K. packed her bags and went to stay with friends, but returned home several days later, feeling remorseful and saying that she wanted to drop the charges against her father. Feeling shocked and humiliated by the arrest and charges of assault brought against him, Mr. K. felt at a loss regarding how best to handle J.K. It was Mrs. K. who proposed family counseling, in recognition of the increasing level of tension and conflict within the family since their immigration from Taiwan eight years earlier. The idea was strongly supported by their attorney, who thought Mr. K. might receive a more favorable sentence at his upcoming trial if he voluntarily sought counseling.

At the intake, the therapist attempted to probe for more specific details regarding the incident, such as the nature of the argument between J.K. and Mrs. K. and what had provoked Mr. K. to intervene at that precise moment. The family was deliberately vague about the details of that evening, however, and instead attempted to minimize the incident. “We are a good family,” said Mr. K., “We love each other. Nothing happened.” Despite their reticence and denial, both Mr. K. and J.K. admitted that they both felt enormous guilt and shame for what had transpired: Mr. K. for striking his grown daughter and J.K. for subjecting her father to the humiliation of police arrest and detention. It was clear that this crisis, culminating in Mr. K.’s arrest, had served to bring the family together in recognition of their need to address their underlying family issues and to support Mr. K in his upcoming trial. J.K. in particular expressed remorse for the suffering she had caused and seemed highly motivated to participate in therapy. It is worth mentioning that Mrs. K. insisted that she be listed as the sole patient in the clinic records. She explained that she was willing to make the sacrifice in order that neither her husband nor daughter would be stigmatized should it become known that they had sought mental health counseling.

C. Psychiatric history and previous treatment

None.

D. Social and development history

Mr. K. was born in the southern part of Taiwan during World War II when Taiwan was under Japanese occupation. His family lived and worked on their small farm and Mr. K. recalls having to endure material deprivation and extreme hardship as a child, which taught him endurance and self-discipline. He recalls that his parents were somewhat distant and very strict with him, beating him when he did things wrong as did most parents of that generation. Upon graduating from university, Mr. K. got a job at a community college where he received numerous teaching awards, of which he was extremely proud.

An ambitious man, Mr. K. gradually grew dissatisfied with his career prospects, despite his enjoyment of teaching. In the early 1980s, he and his family visited his younger brother who was studying in New York. Enamored with the American lifestyle and the educational opportunities for their young daughter, the family decided to apply for immigration to the U.S. After six years on the waiting list, their application was finally approved in late 1988. After careful consideration of the costs and benefits of immigration, Mr. K. decided to move the family to the U.S. in 1989. Their highest concern was that J.K. be able to benefit from the excellent American university system. A second issue was fear of political instability in Taiwan as the result of the perceived threat from Communist China. Although somewhat ambivalent about leaving behind their family, friends and well-paying jobs in Taiwan, the family was hopeful that Mr. and Mrs. K. could find meaningful work and start their lives anew in America.

Shortly after settling in a suburb in the New England area, Mr. K. returned to Taiwan alone to pursue a business opportunity. It was only after the business failed that he decided to return to the U.S. and commit to building a life here. Mr. K.’s efforts to secure a high-status, well-paid position in the U.S. have been frustrated by his poor English-speaking ability, a factor which initially limited him to doing manual labor. Currently he works as a clerk in a car service center, where he feels that his professional skills and capabilities are not fully appreciated. Mr. K. views himself as a rational, intelligent man, yet he has begun feeling increasingly inadequate and frustrated by his professional and financial difficulties since coming to the U.S. Within the family, Mr. K. is perceived as an authority figure who is emotionally reserved yet loving. However in recent years, his relationship with Mrs. K. in particular has become strained, as she bears the brunt of his frustration with life in America.

Mrs. K. stands shorter than her husband and is slightly overweight. She pays careful attention to her appearance as evidenced by the light make-up she wears and her preference for Taiwanese-style fashion. At the initial meeting she presented as superficially warm and eager to be liked. Similar to Mr. K., Mrs. K. spoke of her strict upbringing, recalling that if she did not immediately carry out her father’s orders, she would be physically punished. As a result Mrs. K. developed a propensity to work hard, sacrificing her own needs and wants for the good of her family. She graduated from a nursing school, worked for many years, and was promoted to senior nurse at a community hospital before emigration. At present she works as a nursing assistant in a health care center, does part-time hospice care for the elderly, and is preparing for the board exams that will enable her to work as a nurse practitioner in this country. She is viewed by her family as an energetic and pragmatic person, as evidenced by her efforts to learn English despite her busy schedule. Her willingness to sacrifice for her family has also led her to assume primary responsibility for shopping, cooking and cleaning for the family. Despite her good intentions, she is frequently criticized by both Mr. K. and J.K. for making “careless” mistakes in her haste to fulfill her many commitments. The difficulties she has communicating her own needs result in feelings of resentment and anger, which translate into controlling behavior, particularly with her daughter. Their arguments have increased in frequency and intensity since J.K. entered college three years after coming to the States.

Mr. and Mrs. K.’s daughter J.K. was 23 years old at the time of the intake and had graduated the year before with an undergraduate degree in biology. She is a petite young woman of average looks, whose style of dress marries Taiwanese and American tastes. Aged 15 when she immigrated to the U.S. with her parents, J.K. struggled to learn English and found it difficult to fit in at school. She was also ridiculed for her small size compared to her American peers. During college, J.K. shared a dorm room with several roommates but continued to feel socially and culturally isolated. Since coming to the U.S. she has developed few close friends and has never dated. Her social life consists of attending a Chinese church and participating in youth group activities. After graduation, J.K. took a job working as a health aide at the same health care center where her mother works. Currently living at home, she is saving money to attend graduate school. Although the courts view Mr. K. as the identified patient, J.K.’s complaints focus on her mother, who she views as “pushy,” “nagging,” emotional, and over-involved in her life. In contrast, J.K. presents herself as more similar to her father: rational, deliberate, independent, and capable. The affection between J.K. and her father is evidenced in small ways, warm glances, pats on the back, and the way that she takes his arm when they walk. These displays of affection are not commonly seen in Chinese culture and suggest the fondness that father and daughter feel for one another. Recent difficulties notwithstanding, J.K. states that she continues to feel close to her parents and plans to take care of them in their old age.

E. Family history

There is no family history of mental disorder, although Mrs. K. and J.K. present some symptoms of anxiety and depression. Mrs. K in particular reports persistent irritability, sleep problems and appetite loss that developed only after immigration. These symptoms intensified shortly after J.K. moved back home, suggesting that Mrs. K’s response to this stressor may also meet criteria for an adjustment disorder. All family members report that prior to the current incident there had been no instances of physical or verbal abuse within the home. J.K. herself reported that her father had only applied physical punishment a handful of times in her life, which helps to explain her response of shock and anger in this particular instance.

F. Course and outcome

The family chose to seek services at a community health center located in Chinatown because of their need for a Mandarin-speaking therapist. A total of twenty sessions of family therapy were provided between February 1997 and March 1999, including the eight sessions provided in the weeks before Mr. K.’s August 1997 court date. The focus was crisis intervention and the provision of emotional support for the family. The therapist emphasized open communication and facilitated family discussions about key relationship issues. The use of focused discussion as a means of resolving conflicts and differences of opinion was introduced and rehearsed during therapy sessions.

Initially Mr. K. was skeptical and negative about therapy. He was reluctantly compliant, as he cooperated with therapy only as a means of helping his legal case. At the intake he minimized the incident for which he was being charged, asserting that they were a cohesive family and that there was no need for intervention. Although he admitted that it may have been inappropriate to hit his daughter, especially as a grown woman, he defended his actions as warranted under the circumstances: “I was disciplining my daughter because she was being disrespectful. It was the right thing to do.” He added, “[Anyway], it’s within our home. Why does it involve [the legal system]?” Acknowledging that corporal punishment is common in traditional Chinese society, the therapist explained to Mr. K that physical punishment of children to the extent that it leaves a mark on the skin constitutes child abuse under U.S. law. Mr. K. and Mrs. K. were incredulous that the government could intrude in what they considered a private family matter, but agreed to cooperate with the therapist.

Early on it was observed that members of the K. family frequently engaged in heated arguments and exchanged insulting remarks while avoiding underlying issues. In order to deflect attention away from Mr. K. and allow him to feel more comfortable in the therapeutic environment, the initial sessions centered on the conflicts between Mrs. K. and J.K. Mr. K. was invited to provide his observations and serve as mediator in these discussions. The therapist conceptualized these conflicts as resulting from a growing cultural gap between J.K. and her parents. J.K.’s direct, confrontational communication style and efforts to assert her developing sense of autonomy were viewed as disrespectful, selfish and even “abusive” by Mr. and Mrs. K. From J.K.’s perspective, her parents’ efforts to provide guidance and counsel in her daily affairs were experienced as invasive, patronizing and judgmental. Discussion of these feelings and resulting dynamics worked to diffuse the anger that had characterized the early sessions. Over time Mr. K became more involved, as he began to realize that family therapy was not intended to humiliate him and could actually enhance family communication. Indeed after the first month of therapy, all of the family members began to actively “use” the therapy space as an opportunity to raise individual concerns and work through family conflicts.

For example, a few weeks into therapy Mrs. K. expressed disappointment and frustration that her family did not appreciate the sacrifices and contribution that she makes to the household. In particular she did not feel supported by Mr. K., who she felt criticized her unjustly and blamed her for their financial difficulties, a behavioral pattern that was being mimicked by J.K. At the time Mr. K admitted that he had been more irritable due to his dissatisfaction with his job, and J.K. acknowledged that she would try to help out more around the house. However it was only several months later that Mr. K. was able to acknowledge his own feelings of insecurity and inadequacy due to his failure to secure a high-paying position in the U.S.

After eight sessions the therapist sent a recommendation to the courts for continued family therapy, stating that Mr. K. met criteria for an adjustment disorder and that he had no history of physical abuse to his children. The letter described Mr. K. as a caring father with a traditional authoritarian style of parenting. The court accepted the recommendation for additional counseling and sentenced Mr. K. to up to two more years of family therapy on a monthly basis.

Significant improvement in the relationship between J.K. and Mrs. K. was observed three months after therapy started. Mrs. K. was beginning to respect the decisions J.K. made for herself, and J.K. had learned to express her feelings in a direct but gentle way that did not provoke Mrs. K. In addition, the family began acknowledging that Mrs. K. was shouldering an unfair amount of the housework and negotiated ways to more equally distribute the work. After the ninth session, the therapist saw the family only once a month, a minimum set by the courts. For the next eight months, the family worked on improving communication and strengthening their ability to negotiate their evolving needs within the family. With the initial crisis beginning to fade in their minds, the family began to discuss their long-term plans during the second year of treatment. Mr. K. voiced his feelings of inferiority and worthlessness related to his difficulties adjusting to the U.S. His desire to own his own business was explored and eventually supported by the family, who recognized his need for financial and personal achievement. In the later months of the therapy, Mrs. K. and J.K. had begun rallying around Mr. K. and making plans to save money so that he could open a restaurant in a few years. Treatment was terminated after two years based on the family’s assessment that their relationship problems had been satisfactorily resolved.

G. Diagnostic formulation

Differential Diagnosis

While some decline in functioning is to be expected following immigration, the marked decline in Mr. K.’s emotional and relational capacities over the four months prior to presentation at the clinic suggests a diagnosis of adjustment disorder. The identifiable stressor in this case was J.K.’s move back into her parents’ home, a change that markedly intensified the level of family conflict around issues of separation and individuation and Chinese versus American models of parenting. Mr. K.’s physical assault occurred four months after J.K.’s return. The DSM-IV criteria for adjustment disorder requires “the development of emotional or behavioral symptoms in response to an identifiable stressor(s) occurring within 3 months of the onset of the stressor(s).” In this case the escalating tension between J.K. and her parents that developed within three months before the assault can be seen as the stressor for Mr. K. With regard to alternate diagnoses, there was no evidence to suggest that Mr. K’s aggressive actions were the result of physical illness or trauma. The absence of clinically significant mood and neurovegetative symptoms also excludes the possibility of a mood or anxiety disorder. However, Mr. K.’s inflexible and rigid personality characteristics (i.e., obsessive-compulsive personality traits) may contribute to his acculturation and adjustment difficulties.

Cultural formulation

A. Cultural identity

1. Cultural reference group.

Mr. K. and Mrs. K. are first generation immigrants from Taiwan. Both Mr. and Mrs. K were educated and worked many years in Taiwan and immigrated to the U.S. at ages 47 and 35, respectively. They identify themselves as Taiwanese and adhere firmly to their traditional cultural values and practices with regard to gender and parenting roles. In contrast, J.K.’s immigration during her teenage years and education in the U.S. has facilitated her adjustment and provided greater access and opportunity to engage with the host culture. She regards herself as bicultural, having inherited values and traits from both Taiwanese and American cultures that may occasionally come in conflict. Like many immigrant families in the U.S., the K. family struggles to negotiate differences in cultural practice resulting from different rates of acculturation between parent and child.

2. Language.

The family communicates in Taiwanese at home, although all of them can speak Mandarin, the official language of Taiwan. Despite having been in the U.S. for approximately the same period of time, their level of English fluency varies dramatically. J.K. speaks fluent English, Mrs. K. has a moderate command of the language, while Mr. K.’s English-speaking ability remains poor. Therapy sessions were conducted in Mandarin, with rare use of English words or phrases.

3. Cultural factors in development.

The immigration story of the K. family exemplifies the popular trend of outward migration from Taiwan in search of educational and occupational opportunities, particularly for one’s children. As have so many immigrants before them, Mr. and Mrs. K. left behind their relatives and friends, professional jobs and social status to start life anew in the U.S. Although they were educated and came to the U.S. voluntarily, Mr. and Mrs. K nevertheless found themselves struggling to find meaningful work, to communicate with mainstream society, and to negotiate the cultural conflicts emerging within their own home.

The loss of social status was particularly difficult for Mr. K., which, combined with his limited English-speaking ability, led him to feel that his position as head of the family was in jeopardy. Discouraged by his poor job prospects in the U.S., he repeatedly made plans to return to Taiwan to seek investment opportunities, only to be reminded by Mrs. K. of his past losses. While Mr. K. blamed his wife for not being supportive of his ambition, Mrs. K. felt overwhelmed by the responsibility of juggling work and study in addition to the day-to-day tasks of cooking, cleaning and shopping for the family. In accordance with traditional Confucian gender role ideals, Mr. K.’s self-esteem and identity was tied to his ability to financially support his family, while Mrs. K.’s was grounded in her ability to nurture and care for their physical and developmental needs. The negative feedback they each received with regard to their efforts to fulfill their roles was instrumental in producing feelings of inadequacy, depression, resentment, and anger, which adversely affected the quality of their marital relationship.

In addition, Mr. and Mrs. K.’s difficulties relating to their daughter appeared to stem in part from their high expectations of the parent-child relationship, grounded in their own upbringing within the Confucian tradition. The hierarchical family structure within which both had been reared had as its backbone the concept of filial piety, which they honored within their own families of origin. In turn, they expected their own daughter to be respectful and obedient and to show deference to them. Traditionally children are expected to keep their opinions to themselves and yield to the judgment of their parents. When children grow into adulthood, they are given more trust and responsibility. Yet the hierarchy remains essentially unchanged and is to be observed strictly.

Having grown into young adulthood in the U.S. however, J.K. views herself as independent and autonomous and no longer subject to her parents’ control. Similar to her American peers, she has developed egalitarian values and believes in her right to freely express her opinions. She is assertive and staunchly defends her position when arguing with her parents, who interpret her actions as highly disrespectful. While in mainstream American society the late teens and early twenties are devoted to the task of separation and individuation from the parental unit, J.K.’s efforts to meet this developmental challenge were criticized by her parents, who view such practices as contradicting the traditional norm of a collective family identity with intertwined interests.

4. Involvement with culture of origin.

Mr. and Mrs. K. associate primarily with other Chinese immigrants, eat Chinese food, read Chinese papers, and listen to Chinese radio broadcasts. In addition Mr. and Mrs. K make frequent phone calls to friends and relatives in Taiwan. The family is active in a Chinese Christian church, which serves as an important source of support for the family. Although J.K. is well versed in American culture, she feels most comfortable with other first-generation Chinese.

5. Involvement with host culture.

Overall, Mr. and Mrs. K are in an early stage of acculturation to American society, with Mr. K. having comparatively fewer opportunities to interact with non-Chinese-speaking coworkers due to the nature of his job. Although J.K.’s college roommates were themselves non-Chinese, she has not developed any lasting social relationships with non-Chinese individuals. However she does enjoy watching American television and movies with her Chinese-American friends.

B. Cultural explanation of the illness

1. Predominant idioms of distress and local illness categories.

Mr. K.’s attempt to physically punish his daughter for her insolence was legally described as an “assault” by the justice system. In the case of domestic abuse involving family or household members, the police are required to arrest the perpetrator in accordance with state law. As such, his actions were subject to criminal prosecution despite his daughter’s desire to withdraw charges two days after the event.

In the intake session, Mr. K. situated the primary relational problem between his wife and daughter and defended his own actions as an effort to intervene on his wife’s behalf. Mr. K.’s statement that J.K. was “out of control” reveals his perception that her actions towards her mother were grossly inappropriate and deserving of punishment. In light of his diminished sense of power and esteem in the workplace (a primary component of his identity), Mr. K.’s assault on J.K. may be considered as an attempt to re-assert his authority and to re-establish order and hierarchy in his family through the use of physical power.

Although denying that his actions were deserving of criminal prosecution, Mr. K. and his family did agree that the incident revealed fragmentation within the family and a significant breakdown in communication. Therapy helped the family to articulate the ways in which the stresses of immigration and acculturation were affecting their own self-esteem and ability to care for one another. By the end of treatment the family had conceptualized the precipitating event as a wake-up call to address the growing cultural gap between J.K. and her parents.

2. Meaning and severity of symptoms in relation to cultural norms.

Chinese cultural norms privilege the interests of the family over the interests of the individual. Harmony is highly prized and is preserved through a complex social hierarchy based upon age, gender and social class. Within this hierarchy, an individual’s role and status is clear and there is an expectation that individuals will conform to those roles in the interest of their interpersonal relationships. Within this cultural system, J.K. would be considered by members of her parents’ generation to be a disrespectful, unfilial and selfish daughter. Traditionally Mr. K., as head of the household, has the authority to do whatever is necessary to restore order and to encourage his daughter to conform to her expected role within the family. When verbal reprimands are not successful, corporal punishment is employed as a common means of disciplining a child. In their recently released report, the Asian Task Force Against Domestic Violence found that 61 percent of Chinese-American respondents were hit regularly by their parents while growing up.

Nevertheless, the need to use physical punishment on a fully-grown child as in this case is fairly unusual. On the other hand, it is also rare for a Chinese daughter to be verbally abusive, raise her voice, and confront her parents in a defiant manner. Based on these cultural norms, it is unlikely that a jury of Mr. K.’s peers would consider his behavior unjustified.

It is also worth noting that if a similar event had occurred in Taiwan, it is unlikely that J.K. would have called the police, knowing that her behavior would be looked down upon in the context of cultural norms, while that of her father would be supported. However having lived in the U.S. for the past eight years, J.K. had developed a more Americanized view of her rights as an individual, which she felt were violated when her father struck her. Recalling that she had learned that “in the U.S., parents cannot hit their children,” she called the police, who arrested Mr. K. on the spot. Differences in interpretations of “cultural norms” and the “severity” of both J.K.’s and Mr. K.’s actions in this case highlight the ways in which the boundaries of the parent-child relationship may be routinely contested across generational, cultural and legal lines.

3. Perceived causes and explanatory models.

As discussed previously, Mr. K.’s understanding of the legitimacy of his own actions is supported by a traditional Chinese value system that is not reflected in the cultural milieu within which his family now lives. His impulsive decision to physically restrain J.K. reveals his sense of powerlessness as the traditional father of a daughter who is rapidly acculturating to a new way of life. According to Mr. K.:

Mr. K.’s explanatory model (EM) is one of escalating family tension as the result of adjustment difficulties combined with impulsive action. He reserves his anger and blame for the police department and judicial system:

Mrs. K. also characterized Mr. K.’s actions as regrettable. However, she defended in principle his efforts to discipline their daughter, whom she characterized as ungrateful for the sacrifices they were making for her:

J.K.’s explanation of the event emphasized the out-of-the-ordinary nature of the event as well as her frustration with her mother’s seeming ineptitude compared to the American cultural models with which she was being presented. Even by the end of therapy, J.K. was unable to develop empathy for her mother’s value position, although she did learn more effective ways of communicating with her. J.K.’s feeling of superiority is apparent in the disparaging way she describes her mother and the critical tone used when addressing her directly in session. Anecdotal evidence suggests that this phenomenon is common among children who are more acculturated than their parents, both culturally and linguistically. The overturning of the traditional power structure is fueled by J.K.’s perception of herself as more capable and more independent than her own mother. Interestingly, this projection is not extended to her father, with whom she continues to align, perhaps out of feelings of guilt:

From the court’s perspective, it was determined that Mr. K. physically abused his daughter on the basis of the following evidence: J.K.’s report to the police that her father assaulted her, documentation of her injury by a local hospital, and Mr. K.’s admission that he attempted to slap J.K. Although assault is a crime punishable by a jail sentence, Mr. K. was only placed on probation based on the fact that he did not have a previous criminal record and the court’s consideration that his actions would be considered more tolerable within the Chinese cultural context. Nevertheless, Mr. K.’s behavior was considered deviant and criminal in nature and he was mandated to undergo mental health counseling for up to two more years. The medicalization of the family’s adjustment difficulties as evidenced by Mr. K.’s act of violence was reinforced by the legal system as well as the clinic. From the perspective of the court, the diagnosis of adjustment disorder suggested a temporary lapse in functioning amenable to rehabilitation versus an entrenched characterological problem. From the perspective of the therapist, the use of the diagnosis served to contextualize and to some degree normalize Mr. K.’s behavior by extending the focus of discussion to the social and environmental forces that were stressing the family’s coping abilities.

4. Help-seeking experiences and plans.

At the advice of their attorney, the K. family sought counseling prior to their court date to demonstrate Mr. K.’s willingness to take responsibility for his actions. The family elected to undergo family therapy rather than individual therapy since they considered this a family issue and they did not want Mr. K. to be singled out as a patient. Mrs. K., who appeared to bear the brunt of Mr. K. and J.K.’s distress, also hoped that family counseling could improve the dynamics in the family and address her own feelings of dissatisfaction. The K. family chose to go to an ethnic-specific community health center located in the Chinatown district because of their preference for a therapist of their same cultural background who could speak Chinese. That the family willingly sought and complied with mental health treatment over a two-year period is highly unusual, and reflected initially their pragmatic understanding of how to win a more favorable sentence, and only later their loyalty and commitment to improving family functioning.

The stigma and humiliation experienced by Mr. K. at the hands of the police and the legal system was compounded by his referral for psychotherapy, associated in his mind with the insane. Drawing on his professional experience working with Chinese immigrants as well as his first-hand knowledge of the Chinese cultural context, the therapist devoted a great deal of time in the initial interview to engaging Mr. K. and his family and educating them about the benefits of psychotherapy for the general public. As with many Chinese, the K. family had no previous experience with psychotherapy. Yet by the end of the treatment period, their satisfaction with the gains made in therapy suggested that they would be more likely to voluntarily seek mental health services in the future should the need arise.

C. Cultural factors related to psychosocial environment and levels of functioning

1. Social stressors.

As discussed above, all three members of the K. family have been significantly affected by a number of sociocultural forces that have stressed their coping capacities. These include challenges associated with immigration, such as language barriers, their decline in social and economic status, and loss of extended family support. In addition, the process of acculturation and the concomitant challenge to traditional culture has produced profoundly different solutions and activated vulnerabilities which have distanced the family from one another. Chinese cultural traditions, which emphasize harmony, conformity and hierarchy within the family, have proven to be particularly problematic for J.K. While her relatively faster acculturation to mainstream American culture has enabled her to succeed academically and professionally, she has begun to question her parents’ presumed authority to intervene in her life.

2. Social supports.

The K. family is active in a Chinese church where they have become acquainted with many other immigrants from Taiwan, Mainland China and Hong Kong. Apart from the Chinese church, the K. family has limited social support here in the U.S. Mr. K.’s brother, who sponsored the K. family’s immigration, lives in New York; however Mr. K. does not often turn to him for help. Out of shame the family did not discuss their legal difficulties with anyone outside of their immediate family.

3. Levels of functioning and disability.

As with many immigrant families, members of the K. family generally demonstrate high occupational and social functioning despite their subjective experiences of distress. Their family functioning, however, was greatly weakened as the result of acculturative stress, as discussed previously. Mrs. K. in particular displayed significant levels of emotional and somatic symptoms, threatening on more than one occasion that she was prepared to leave the family if things did not improve. Mr. K. also described feelings of disappointment and frustration with his poor job prospects, which he inadvertently took out on his family. Nevertheless, both parents continued to perform well at their jobs and were able to hide their family and legal difficulties from friends and extended family.

D. Cultural elements of the clinician-patient relationship

At his first meeting at the clinic, Mr. K.’s manner and posture suggested feelings of shame as well as indignation. That he felt forced to seek advice on family issues from someone who was several years younger made it particularly difficult for Mr. K. to feel comfortable in the therapeutic milieu. In response, Mr. K. spent quite a bit of time describing his privileged position as a teacher in Taiwan as a means of asserting his age and experience. The language and tone he used was authoritarian in style, much as an elder would address a younger colleague, signaling his desire to be treated with respect.

Understanding this dynamic, the therapist was careful to show respect to Mr. K. and to acknowledge his authority within the family. It was only after he saw that the therapist was supportive and non-judgmental, and that his participation in therapy could help his case, that Mr. K. became more engaged and invested in treatment. The fact that the therapist himself was an educated Chinese male who had also worked in Taiwan greatly facilitated communication and mutual understanding. People in the K. family, with their traditional respect for doctors, formed a positive transference toward the therapist, making it easier for therapeutic change to take place.

E. Overall cultural assessment

Adjustment disorder is a broad and sometimes ambiguous diagnosis that indicates an excessive reaction to stress with impairment in social and/or occupational functioning. This case demonstrates that chronic stresses associated with immigration and acculturation may produce substantial functional and interpersonal difficulties. The different lenses—cultural, familial, legal, medical—through which the K. family’s adjustment difficulties may be viewed illustrate the complex task of negotiating competing cultural norms, interpretations, and solutions. The question is also raised: when norms differ, which ones should be used?

In this case, Mr. K.’s action towards his daughter was first criminalized, then medicalized as a symptom of a psychological problem in need of clinical attention. Certainly, domestic abuse laws are designed to protect an individual from an abusive household member. However it is also important to acknowledge that the U.S. legal system assumes a certain set of values with regard to individual rights that may not be shared across cultural groups. Indeed, in Mr. K.’s worldview, his right to discipline his daughter was violated while his belligerent daughter’s rights were protected, a reversal of power which he had little ability to comprehend.

Nevertheless, these beliefs regarding autonomy and human rights are being gradually assimilated by J.K., whose resulting assertiveness and independence run in stark contrast to her parents’ value system. In addition, the therapist felt it was important for Mr. and Mrs. K. to understand the mainstream value system as a means of improving their adjustment to life in America.

The therapist’s task then, in this case, was to (1) educate the family about the laws and values in this country and (2) help the family articulate and work through their differing perspectives, values and expectations of one another. The therapist’s ability to understand Mr. K.’s explanatory model as supported by cultural norms allowed him to empathize, rather than judge him for the criminal charges brought against him. While not condoning his actions, the therapist was thus able to build an alliance with Mr. K. that aided the process of family therapy. Through improving their ability to communicate, the family was better able to negotiate the compromises that were necessary in order to allow them to reestablish a mutually supportive family structure.