This article addresses cultural differences in family dynamics, introducing a few fundamental concepts and covering important questions that need to be asked by providers to understand the family experience unique to each individual patient and how that affects decision-making, compliance, and successful treatment outcomes.
Individuality vs. Interdependence
Cultures differ in how much they encourage individuality and uniqueness vs. conformity and interdependence. Individualistic cultures stress self-reliance, decision-making based on individual needs, and the right to a private life. In collectivist cultures absolute loyalty is expected to one’s immediate and extended family/tribe. The term familism is often used to describe the dominant social pattern where decision-making processes emphasize the needs of the family/group first, and the concept of having a “private life” may not even exist.
Nuclear vs. Extended Family Models
In western cultures, and particularly in European American culture, families typically follow a nuclear model comprised of parents and their children. When important health care-related decisions must be made, it is usually the parents who decide, though children are raised to think for themselves and are encouraged to act as age-appropriate decision makers as well. Upon reaching adulthood, when parental consent is no longer an issue, young American adults may choose to exercise their right to privacy in health care matters. This is markedly different from collectivist cultures that adhere to an extended family model. In cultures such as American Indian, Asian, Hispanic, African, and Middle Eastern, individuals rely heavily on an extended network of reciprocal relationships with parents, siblings, grandparents, aunts and uncles, cousins, and many others. Many of these people are involved in important health care decisions, including some who are unrelated to the patient through blood or marriage. For example, in some Hispanic families the godparents play a critical role. In American Indian families, tribal leaders, the elderly, and medicine men/women are key individuals to be consulted before important decisions are made.
It is very common for families in collectivist cultures to establish multi-generational households. (This is less true when a family becomes acculturated in the United States or other western countries where privacy is more highly valued and in cases where socio-economic gains create opportunities for greater independence.) In most multi-generational households, there are at least three generations living together; the grandparents are expected to live under the same roof as their adult children and grandchildren. In multi-generational households the family of orientation (one’s self, siblings, and parents) often takes precedence over the family of procreation (one’s self, spouse, and offspring). This is the reverse of how European American family households usually function. In traditional Asian families, it is the oldest male in the family who brings his bride to live with his parents. The daughter-in-law is often expected to be submissive to her mother-in-law who rules the roost. In Hispanic families, grandparents from either side may live under that same roof as their children and grandchildren. Mothers often gain a great deal of support from the grandmothers in domestic matters, but this varies depending on the dynamics unique to each family.
It is extremely important for health care providers to ask who lives in a patient’s household in order to better understand how relationships are structured. Who are the authority figures? In Asian and Hispanic traditional families, the father is the main authority figure. He will most often make decisions about matters outside the home, speaking for the family in public settings and signing consent forms. It is usually a female figure who takes charge of domestic life. Depending on the family, this matriarch may be the mother, but it may be the mother’s mother. Thus healthcare providers need to ask the mother, “Who gives you advice about raising your children?” And “who will participate in making important decisions?” In Asian and Hispanic families especially, grandmothers often decide about using traditional medicines and healing practices, thus having enormous influence on patient compliance.
Role Flexibility & Kinship
In dealing with culturally diverse families it is useful for health care professionals to understand the basic concepts of role flexibility and kinship and how these affect family dynamics. American kinship structure is bilateral; we are not “more related” to our father’s family than our mother’s, or vice versa. In unilineal cultures, family membership is traced either through a male or female ancestor. In the Middle East, for example, a patrilineal pattern is established so family belonging is passed via the father’s side. Some American Indian cultures, like the Navaho and Hopi tribes, are matrilineal cultures, passing membership through the mother’s family. In the Navaho tribe, property and privilege are passed from male to male, but it is the mother’s brother who will pass both to his own sister’s children. Thus it makes sense that a Navaho maternal uncle might bring his nephew into the hospital expecting to be empowered to sign an informed consent.
Similarly, in both American Indian and African American families, role flexibility can be an important issue. It is not uncommon for Native American grandparents to raise grandchildren while the parents leave the reservation to find work. In African American families, the mother sometimes plays the role of the father and thus functions as the head of the family. In addition, older children sometimes function as parents or caretakers for younger children. The concept of role flexibility among African American families can be extended to include the parental role assumed by grandfather, grandmother, aunts, and cousins. (Boyd-Franklin 1989) It is a good idea to determine if older children will be involved in patient care and to include them when possible in patient care training. This is important to consider for all multi-generation households.
Family Dynamics and Acculturation
Finally, it is important to consider the enormous stresses families encounter in the process of acculturation due to sudden and radical shifts in family dynamics. Parents in a recently migrated family often are aligned with the culture of the country of origin, while their offspring are likely to adapt to the dominant culture more rapidly. This often leads to intergenerational conflicts. For example, a father may lose his traditional role as the head of the family if his wife begins to work outside the home, earning income and greater independence. Similarly, if his children quickly adopt the attitudes and values of the new dominant culture, he may find it harder to communicate with them. Both parents and grandparents may feel a loss of status due to language barriers, especially if their children learn the language of the dominant culture more quickly. This can be especially problematic in healthcare settings where responsibility is shifted to younger family members who can navigate the health care system better than their parents can. In cases where children are able to communicate with health care workers in English, they may be asked to interpret for their parents. This leads to a host of potential problems for the family, including feelings of shame and betrayal that children would relay information of a personal nature to someone outside the family. This is one of the main reasons children should not be used as interpreters.
Because cultures adapt and change, making assumptions about family dynamics is problematic; families in the United States today from all cultures display a variety of configurations. Arguably, there is no longer any such thing as a “typical” family. One can, however, expect that families from more traditional cultures not acculturated in U.S. ways will tend to value familism and display family structures that are quite different from the middle-class European American family model. There are many aspects of culturally-based family dynamics not addressed within the scope of this newsletter article. Some of the best resources for learning more about cross-cultural family dynamics come from the mental health and child development fields.
A few resources for further learning are listed here.
- Counseling the Culturally Different by Derald Wing Sue and David Sue
- Diagnosis in a Multicultural Context by Freddy A Paniagua
- Kids: How Biology and Culture Shape the Way We Raise Children by M. F. Small
- The Cultural Nature of Human Development by Barbara Rogoff