Dr. Mitchell Hicks presents a case conceptualization of a Latino client presenting with anxiety.
In the present article, I present an example of my work with a Latino male whom I will call “Miguel.” Since this is a treatment that took place a considerable time ago and his current location is unknown, it was not possible to secure his permission to present this case. Therefore, significant details regarding his background and issues presented that may serve to identify him or locate where this treatment took place have been removed, altered, or fictionalized.
Santiago-Rivera, Arredondo, and Gallardo-Cooper (2002) provide important concepts to understand when working with and attempting to establish trust with Latino clients:
Personalismo – orientation toward the person always being more important than the task at hand, including time.
Plática – a form of “personable small talk” linked to personalismo orientation. Engaging in conversation of more personal nature that may include more surface disclosures about therapist and his/her background
Respeto – sensitivity to the individual’s position and creates a boundary within which conversations should be contained to avoid conflict. (Language reinforces hierarchy)
Dignidad – value actions that enhance sense of pride
Simpatía – Easy-going, friendly, and fun persona
Confianza – Development of trust, intimacy, and familiarly (relational)
Cariño – Demonstrations of endearments in verbal and nonverbal communication
Marianismo – girls are to grow up to honor the model of the Virgin Mary: pure, long-suffering, nurturing, and pious.
Machismo – Often stereotyped concept of sexist and chauvinistic behavior. Actually refers to being an honorable and respectable man.
Psychodynamic Theory in General
Moncayo (1998) proposed a reformulation of psychodynamic psychotherapy based on Lacan’s conception of Freud from a postmodern perspective. He argued that for minorities in general, and Latinos in particular, focusing on ego-adaptation to [majority] society is akin to the learning to obey the master. This is rooted primarily in the “American ideology of individualism and the self-made entrepreneur.” In contrast, concentrating on de-repression of unconscious material is akin to emancipation. This does not make the same assumptions about “primitive” defenses. Although I do not completely agree with this stance, it does highlight the need for care in terms of to what the patient is being asked to adapt and may serve to broaden what is considered functional.
Relatedly, some have proposed the concept of “connection/disconnection” to replace the separateness/relatedness dialectic that underlies psychodynamic and systemic thinking (e.g., Jackson & Greene, 2000). Specifically, the ideal of connection refers to being bonded with others, particularly family members, in a manner that personal growth is allowed to occur. Implied in this concept is that being detached and totally autonomous is just as pathological as being so tightly linked that the patient gives up (or is denied) his or her own agency. This concept seems to better articulate a metric by which to judge the health and quality of object relationships by placing the concept of “growth-producing relatedness” at the fore. This may also serve to more accurately represent what the original psychoanalytic and family systems theorists were describing as it has never been considered healthy to achieve a separation that is marked by emotional and relational disengagement.
Miguel is a single Latino male in his 20’s who initially presented for treatment after being referred for psychotherapy by his psychiatrist. At that time, he reported experiencing considerable anxiety most days but denied having panic attacks. He frequently worried about his performance on the job and about making friends. Client indicated that he has always had a small amount of anxiety, but that it increased exponentially during his first semester in college. His symptoms were so strong at that time that he performed poorly in most of his classes, which increased his anxiety. He now fears that he may not be successful in his new employment situation. At that time, it seemed as if one of his core concerns was tension between his religious values with regard to sexual behavior (e.g., no masturbation, remain a virgin) and his very active sexual fantasy life, strong libido, frequent masturbation and viewing pornography. In addition to the guilt he felt with this struggle, he seemed fairly isolated. When I began seeing him, he had done little work on the sexual issues as he was uncomfortable discussing them with a previous therapist, who was female. In addition to the above stated problems, later in treatment he evidenced symptoms consistent with Obsessive-Compulsive Disorder (e.g., fear that angry gay men will rape and kill him, which provoked considerable anxiety that he quelled by “not making them mad,” avoiding them, and sleeping with a handgun next to his bed for protection).
Miguel is Latino-American and grew up on the West Coast. Client’s mother is a Mexican American born in the southwestern United States and his father emigrated from South America. His family is probably upper-middle class and lived in a predominantly White area of the city in which he was raised. Client experienced considerable discrimination in school as he was mistreated by Whites because he was Latino and by other Latinos because his family had some money and they thought he was “too White” and a “sell out.” Client expressed considerable pain over this dual rejection. To compound matters, client reported that his father seemed to want to bury his cultural heritage. Miguel indicated that he has longed for connection with Latino friends, but has been only modestly successful in securing them. Although he spoke Spanish, it was unclear whether English or Spanish is the preferred language in the home (or some combination).
Client also reported that his Christian faith was very important to him and that he tried to live in accordance with its precepts. It was important in therapy to frame interventions in such a way as to make it clear that the goal is not to undermine them.
Further Psychosocial History
Client was the only child in his family. He reported that he and his father have not always gotten along as they would “fight for power,” and experienced him as cold and distant. Client believed that this situation has improved after his father took a new job that was less stressful. He described his mother has “strict” and “overprotective,” and felt that he had a good relationship with her. He indicated little connection with his extended family. Client reported that he talked to his parents about twice a week via telephone, but thought that perhaps this was too frequent. He described their relationship as “close,” and that he is happy that he has been able to have a better relationship with his father in recent years.
Outside the family, the client reports having “close” relationships with a woman friend and her boyfriend, but “they have lives too.” While he did interact with this couple and a few other acquaintances, he reported feeling considerably isolated. In dating relationships, he reported that he was usually pushed away by women in whom he had expressed a romantic interest.
Client indicated that he had never had a serious romantic relationship. Although he had been on several dates during our treatment, he always ended up terminating the relationship because “she might want to have sex,” or “people will think that I can do better or that I’m just using her for sex,” or “she’s just not the perfect girl.” It was observed by both myself and support staff that he made passes at about every woman in the waiting area, and had seemed socially awkward at those times. Moreover, he reported high levels of arousal when he saw beautiful women anywhere. Previous therapist indicated that he was appropriate with her until treatment ended, but things changed when he ran into her at the grocery store. She reported that he hit on her at that time, and did not seem to comprehend her explanation of ethical boundaries. With regard to sex, client indicated that the messages he got from home were “don’t do it” and “sex is bad.”
Miguel did not really have any close friends, but did identify a few people with whom he had been able to form some relationship. Notable was another Latino man with whom he worked and who started at about the same time. In this situation, client felt that they were developing a close relationship, but his parents told him to stop because the man reportedly sounded “gay” to them. Miguel could not identify anything to support this conclusion, although he did honor his parent’s wishes.
Educationally, Miguel struggled. At the time of treatment, he was working at his job much of the time, and had a pretty strict regimen that the kept faithfully. He felt that his anxiety kept him from performing better both educationally and in his current employment. However, he seemed to not grasp that it may also negatively impact interpersonal relationships.
At his core, Miguel seemed to have a sense of himself as unlovable, weak, and defective. This gave rise to intense feelings of shame, especially as the threat of exposure looms and he developed increasing awareness of his need for connection. The possibility of being exposed led him to ward off intimacy and its accompanying anxiety with a sexualization of it. However, another twist occurred as he projected onto women (and arguably men as well: see below) his desire for them as “maybe she wants me to be her boyfriend” or “she’ll want to have sex,” thus he felt unable to continue these relationships. He also put out an air that he was special or better than others around him for one reason or another (e.g., superior work habits), yet was jealous when others received recognition or promotion after what he felt was far less effort.
Complicating the picture is some of the content of his obsessions. His tendencies toward perfectionism, order, and routine not only served to bolster his self-esteem, but also to ward off anxiety about his “true self.” Some of the content of his obsessions, particularly his fear of homosexuals, raised questions about a component of the true self. I would like to pose three hypotheses. First, he may have somewhat typical thoughts about the attractiveness of men that he latched onto with such ferocity that he started to believe himself to be gay. He then warded this off by projecting his feelings and possibly self-loathe onto men he perceived to be gay (irrespective of whether or not they were). Second, he likely longed for deep emotional intimacy in general, and with men in particular. If so, his obsessions may be linked to a fear of intimacy itself and used their perceived sexual orientation as an excuse to put distance between them. Finally, he may have been bisexual or homosexual himself, and may have been unable to accept this. Not only did he fend off this anxiety though projective identification with perceived gay men, he might have been sexualizing relationships with women to prove how heterosexual he is. Unfortunately, treatment did not last long enough to fully explore these hypotheses due to a change in the therapist’s work situation.
Reflections on the Process of Treatment
One major challenge in working with Miguel was that our work required a stylistic shift. As is typical with more psychoanalytically informed treatment, I initially was resistant to conversations of a more personal nature. It was typical for Miguel to begin sessions seeking some type of personal information from me, but interpreting this was not only futile but a technical error. As stated above, many Latino clients expect to engage in some level of platicar and place relationship above tasks. Early in the treatment, I fortunately learned about this aspect of the culture and was able to modify my approach and expectations accordingly. This became a fruitful engagement that allowed for the development of trust and deepened explorations.
Another challenge was attempting to discern to what extent his relationships with his parents reflected culturally-appropriate connection or some state of dysfunction. This was complicated in part by what seemed to be discomfort with exploring his childhood history and family dynamics with any level of depth. However, with some gentle questioning he did begin to question the quality of connection. Although this issue was never fully explored or resolved, it was my intention to respect his decision to not in any way dishonor his parents while still asking him to reflect. It was my hope that any conclusions he drew were his own and not coming from my cultural framework.
Finally, Miguel seemed to experience a lot of self-hatred as well as difficulty in figuring out where exactly he belonged. His identity as a Latino male had been undermined due to the discrimination and rejection that he experienced from both Whites and other Latinos. Although it is unclear to what extent family dynamics contributed to this, Miguel seemed to have a relational pattern of desperately wanting to be cared for and accepted by others that ultimately resulted in rejection as he engaged in behaviors and employed defensive maneuvers that served to keep him distant. In addition to a few examples cited above, in our sessions he would miss appointments whenever he experienced a hint of authentic connection with me.
Although Miguel struggled with relationships, work, and even in our relationship, it was always clear that he took the mandate to be an honorable and respectable man very seriously. It was a privilege to work with him, and I grew in several important ways. First, my horizons of what manhood means and how that interacts with other cultural considerations was broadened. Second, I came to understand some of the methods of psychoanalytic psychotherapy that I had been taught needed some adjustment to account for different ways of relating. Allowing myself to “break the rules” in this case led to a much more satisfying therapy relationship in which some important truths about the symptoms he was experiencing and how they were affecting him could be discussed. I believe this also allowed him to hear my request that he not hit on women in the waiting room and not damage his sense that I thought well of him.
-Originally published in the SPSMM Bulletin, Spring 2007
Mitchell Hicks, PhD Independent Practice Assistant Professor of Counseling and Human Services Roosevelt University