Vignette Jasmin is a 21-year-old Asian woman who immigrated to the United States 10 years ago. She is an intelligent college student and she likes to study, although she has been diagnosed with ADHD and dyslexia. She lives together with her parents, young sister and older brother. Jasmin's younger sister is in high school and her brother works at the father's grocery store. Her father has high blood pressure and needs to rest but continues to work at the store. Her mother also worked at father's grocery store.

The patient is taking Concerta. If she skips medication, she cannot concentrate on her studies and finds it difficult to talk to the other students. Her adviser is concerned about her ADHD and her difficult concentration. At the intake and opening the session with Jasmin, the client reported that she felt somewhat depressed, unmotivated, and self-destructive. She added that she felt she set herself up to fail, but she also said she wanted to be productive, happy, and confident. She reported that she does not like to write essays citing time constraints. She is confused about how to think about her future goals.

In the session, she told me about she had both ADD and Dyslexia. She has trouble concentrating even on reading books if she skips her medications. Jasmin clearly explained to me that her family has been pressuring her, and she feels that she should obey her father's wish for her to enter into an arrangement marriage. Jasmin was crying during the session because she is depressed about her unclear future. She has had boyfriends in the past, but does not know how to reconcile her own goals with the demands of her parents. When I asked her about family, she told me that her family lives together and also works together. Her family is influenced by their Asian culture and is male dominant. Her mother always obeys her husband. When Jasmin was a child, her mother was strict and gave her a lot of advice about woman's work their social roles. Her mother concentrates on taking care of her younger sister, and the patient feels her relationship to her mother is not close and they disagree on many issues especially about the client's future.

Treatment Plan

The two treatment objectives will be to strengthen Jasmin's confidence and self of self, and to involve her family in strength-based family counseling. Initially, we will need to continue seeking more information about the client and her family of origin. We need to clarify treatment goals and in the next session I would like to speak with the client about her concentration issues and the way Concerta helps her and what side effects she might be experiencing. Next session, I would like to ask her about how Concerta affects her concentration and investigate the possibility that depression could also be an issue for Jasmin. I also want to ask her about her views on relationships and gender roles, and then I hope to address the relationship with her mother and father through the lens of family systems theory.

Family Systems Theory

This treatment plan will be based on family systems theory, because I believe the client's psychosocial problems are related to the conflict between her values and those of her family. Family systems theory allows for cultural context, showing that it is "necessary to understand the problem and/or to create a treatment plan that shows sensitivity to the norms, rules, and values of the client's cultural group," (Ingram, 2006, p. 340). The client's problems must also be understood "in the context of the entire family system," and not as if the problems Jasmin faces are isolated from issues like social role performance (Ingram, 2006, p. 340). I hypothesize that social role performance is a major issue for Jasmin, contributing significantly to her distress and dysfunction (Ingram, 2006, p. 340). Whereas family might have been a bastion of social and psychological strength in static and homogenous societies, in progressive, dynamic, and heterogeneous societies the family can become one of the greatest sources of stress in a person's life.

The Jones-Smith (2013) theory of strength-based family therapy shows how to focus on the positive aspects of Jasmin's family life instead of the negative. This way, Jasmin can capitalize on the closeness of her family. Her family is comprised of individuals who care deeply about each other, which is why her siblings and her mother work in her father's store. Jasmin may see herself as an outsider because she has different goals than to work in her father's store. Perhaps she feels afraid to confront her parents about this issue,...

If Jasmin can conceptualize her role as being an insider and not an outsider, shifting her mental framework might help her considerably. As Jones-Smith (2013) points out, "individual family members will have different strengths that they contribute to the unit," (p. 202). Using a strengths-based approach, Jasmin can list all the strong qualities that her mother and father bring to the family, while also recognizing her own contributions. When we can eventually have a family counseling session (a core treatment goal), then we can work on helping Jasmin's father and mother also appreciate Jasmin's strengths rather than focusing on her divergence from traditional family and gender norms.
To work on strengthening the family we can begin by recognizing the value of its rituals. Jasmin can talk about the activities, including cultural and religious ceremonies that bring together her immediate and extended family. "Family history can serve as a bond among family members when family members tell favorite family stories," (p. 202). As a therapist, I will ask Jasmin and her family members about their shared stories and rituals so that we can emphasize those instead of what is drawing them apart from one another.

Depression and ADHD

Jasmin has been diagnosed with ADHD and is taking medications for the inability to concentrate, which interferes with her school and her social life. I would also like to address her apparent depression and social anxiety without jumping to any diagnostic conclusions. As Targum, Nakagawa & Sato (2013) point out, even the standardized measures of assessing depression can be Euro-centric and the therapist does need to remember that these measures may not reflect the full gamut of experiences of people from other backgrounds. Instead of overestimating the occurrence of her depressive symptoms, the therapist can engage with Jasmin about her personal narrative (Lehti, Hammarstrom & Mattsson, 2009). As with all narratives, the hero does go through ups and downs as part of their character and strength-building, so depressive symptoms should not be viewed as something to be afraid of or something to be medicated. We can address Jasmin's need for ADHD medication separately.

Timmi & Taylor (2003) point out that "there are no specific cognitive, metabolic or neurological markers and no medical tests for ADHD," and because of this, the condition may be culturally specific and even dangerous to diagnose (p. 8). Medicating an issue like concentration can prevent people like Jasmin from squarely confronting the root causes of her inability to concentrate or communicate without her medication. I am not suggesting that she stop taking what helps her, but I am suggesting a more holistic and family systems approach. We need to bring her family into therapy, and help Jasmin develop a stronger sense of self. Career counseling and other methods to inspire her to have a stronger vision for the future may help her to confront her parents while still being an integral member of the family. We can meet the two core treatment objectives by focusing more on Jasmin's vision for the future, which can be distinct from her parent's vision for her.

Cross-Cultural Perspectives: What I Have Learned

It is my belief that Jasmin is uniquely situated at the intersection of two generations and two cultures, and that her stance makes her feel alone and isolated as well as confused about her role in the family and in society. Her entire identity is in flux because she no longer values what her parents value, or at least she believes that to be the case especially regarding women's role in the society. Instead of accepting that Jasmin has been adapting to the new culture and adopting the new culture's gender roles and norms, her family pressures Jasmin to conform to their ideals. This is creating significant role conflict and identity conflict for Jasmin, who needs to feel at once a part of her family and also a part of the greater society. Jasmin's case highlights some of the challenges of working with clients from different cultural backgrounds, especially immigrant families who might be experiencing conflicts due to generational differences.

As the American Psychological Association (2003) puts it, "cultures differ in basic premises that shape worldview," (Guideline 1). Instead of assuming that Jasmin's worldview is directly influenced and shaped indelibly by her family and cultural background, the therapist should be allowing Jasmin to share her beliefs…