Cultural Differences in Residential Child and Youth Care: Analyzing Perspectives

Cultural Differences in Residential Childand Youth Care: Analyzing Perspectives

Mariska KromhoutLotty ElderingErik J. Knorth

Leiden University

ABSTRACT: In many Western-European countries, clients from ethnic minority groupsform an increasingly large proportion of the client population of child and youth carecenters. This development raises the question of how to respond to cultural differencesbetween professionals and clients. In this article we discuss the concepts “clinical reality,”“world view,” and “acculturation” to provide a theoretical framework for studying theinfluence of cultural differences on the care and support process. We focus on Moroccanyouth in Dutch residential youth care centers and present a case from our study toillustrate the theoretical issues raised.

KEY WORDS: ethnic minorities; multicultural youth care; cultural differences.

In the last few decades many countries in Western Europe havereceived increasing numbers of immigrants from former colonies, oftenas a result of granting independence, guest workers from Mediterra-nean lands, and asylum seekers and refugees from countries all overthe world. In the Netherlands this process has resulted in the presenceof a number of ethnic minority groups. The largest group is the Surina-mese, followed by the Turks, Moroccans, and Antillians/Arubans re-spectively1 (Centraal Bureau voor de Statistiek [CBS], 1998a). TheSurinamese and Antillian/Arubans came from former Dutch colonies.The other groups originally consisted of guest workers (Eldering, 1997).

As a result of the continuing immigration of families in some groupsand the relatively high birth rate in others, the immigrant populationas a whole is composed largely of children and youth (see CBS, 1998b;Martens & Verweij, 1996; Smeets, Martens & Veenman, 1997). Conse-quently, many education, health, and welfare professionals have seen

Correspondence should be directed to Mariska Kromhout, Center for Special Educationand Child Care, PO Box 9555, 2300 RB Leiden, The Netherlands.

Child & Youth Care Forum, 29(6), December 2000 2000 Human Sciences Press, Inc. 359

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an increase of pupils and clients from cultural backgrounds that differfrom their own. This encounter has not always been successful, andthe question for many professionals has been—and still is—how torespond to and engage the cultural differences that influence theirwork.

Until now these issues have received little attention in research onresidential child and youth care. In their 1998 article in this journal,Knorth and Eldering (1998a) gave an overview of the research literatureabout immigrant youth in residential care in the Netherlands. Theystated that more research was needed on the different views whichimmigrant clients and workers from the majority group may have onthe clients’ problems, because such differences may impede the careprocess (see Kleinman, 1980). In this article we present the first caseof a study in which these issues were investigated. Since these issuesare very complex, we decided to conduct an exploratory, qualitativestudy (Knorth & Eldering, 1998b; Kromhout, 1998; Shlasky, 1998). Thedata were analyzed according to the guidelines by Miles and Huberman(1994).

We will first address the issue of cultural differences in the field ofchild and youth care from a theoretical viewpoint, drawing on the workof the psychiatrist-anthropologist Kleinman (1980) and the literatureon multicultural counseling. Secondly, we will present the case of aMoroccan boy in a specialized youth care center. In this case some ofthe theoretical notions are confirmed, while others are not.

Theoretical Background

Clinical Reality

The idea that clients and professionals from different cultural back-grounds (whether caused by education or different ethnic origins) canhave different perspectives on sickness and health (physical or mental)has been elaborated upon by Kleinman (1980). According to Kleinman,every society contains a “health care system,” most often consisting ofthree sectors: the popular (lay), the professional (the organized healingprofessions), and the folk sector (alternative healers). Each sector hasits own way of thinking and acting with regard to sickness and health,but variation within the sectors may occur as a result of differencesin socioeconomic status, education, and ethnicity. The perspective onsickness and health and the associated help-seeking behavior of a cer-tain group in society is called by Kleinman (1980) its clinical reality:“The beliefs, expectations, norms, behaviors, and communicative trans-

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actions associated with sickness, health care seeking, practitioner-pa-tient relationships, therapeutic activities, and evaluation of outcomes”(p. 42).

When lay people seek help in the professional or folk sector they maymeet practitioners with a different “clinical reality.” With regard to thesickness episode in question, the general “clinical reality” of both partieswill be translated into a more specific “Explanatory Model” (EM). EachEM consists, among others, of ideas concerning the causes of the sick-ness, the time and manner of onset of symptoms, the seriousness ofthe sickness, and the most desirable treatment. These ideas may changeand Kleinman supposed that they are partly conscious and partly un-conscious. During communication with the client, the professional triesto elicit the client’s EM and presents his or her own. In the case ofdifferences in EM, the question is whether the professional is or is notable to adequately translate his or her views into a “language” theclient or patient will understand and whether he or she is able andwilling to work within the client’s frame of reference. Kleinman pre-dicted poorer health care outcomes in situations in which a large dis-crepancy between EMs of patients and professionals still remains afterclinical communication. Adriani (1993) showed that these notions canbe very fruitfully applied to (the study of) child and youth care of ethnicminority families in the Netherlands.

World View and Acculturation

In the related field of multicultural counseling, authors often usethe concept of “world view” to describe people’s general perception oftheir relationship with the world, including their ideas about mentalhealth (Grieger & Ponterotto, 1995; Ibrahim, 1991). The generalthought is that counselors and social workers need to assess theirclient’s world view and to operate within that frame of reference to beable to help him or her.

The concept of “acculturation” refers to the process and level of adap-tation of immigrants to the values and norms of the (often white)majority population and the extent to which they want to maintainrelationships with other groups in society. The process of acculturationusually continues for several generations (Berry, 1994). Differences inthe level of acculturation may lead to conflicts between immigrantparents and children (Baptiste, 1993). According to Grieger and Ponter-otto (1995), research on acculturation suggests that it may be related tothe attitudes ethnic minority clients have toward Western-style mentalhealth services.

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Improvement of Care

Based on the idea that cultural discrepancies between (majority)professionals and (ethnic minority) clients negatively influence thequality of services, many improvements have been recommended byauthors in the field of multicultural psychiatry, counseling, and childand youth care. These concern the social services’ organizational levelas well as the level of the individual practitioners (e.g., Adriani, 1993;Hoogsteder, 1996; Hoskins, 1999; Leong, Wagner & Tata, 1995; Ster-man, 1996; Sue, Arredondo & McDavis, 1992). The recommendationsmost often made are:

• employing professionals from ethnic minority groups;• training (majority) professionals in multicultural awareness, atti-

tudes, knowledge and skills;• consulting and collaborating with experts and traditional healers;• making use of interpreters;• using standardized Western assessment tools with great caution and

developing culturally sensitive assessment and (directive) treatmentmethods;

• paying serious attention to material problems and psychosomaticcomplaints;

• accepting and respecting the client’s culturally based explanations;• engaging clients’ family members in the helping process;• paying extra attention to informing clients about the institution;• using decorations from different cultures in the institution;• respecting religious proscriptions (e.g., regarding food, prayer etc.)

in the institution.

Some authors in French ethno-psychiatry even recommended that ther-apists themselves engage in culturally-based explanations and treat-ments (see Sterman, 1996), but not all psychiatrists of non-Westernorigin agree with this (e.g., the Moroccan professionals quoted in VanDijk, 1989).

Many of the recommendations mentioned are based on clinical experi-ence. Although they have clear face validity, most of them lack a soundempirical basis. Atkinson and Lowe (1995), however, concluded fromtheir review of counseling research literature that, all things beingequal, ethnic minority clients do prefer a helper from their own ethnicgroup. They also concluded that clients drop out less and treatmentoutcomes are better when (ethnic minority) clients and therapists arematched on language and ethnicity. Furthermore, cultural responsiv-ity, as shown by a real interest in the clients’ culture and by placingtheir problems in a cultural context, seems to enhance a professional’s

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credibility in the eyes of ethnic minority clients. The same holds forthe use of directive techniques as opposed to non-directive techniquesin counseling.

Multicultural Child and Youth Care in the Netherlands

For a number of years, welfare institutions in the Netherlands havebeen trying to adapt their services to the specific needs of ethnic minor-ity clients (Adriani, 1993; Bellaart & Ferrier, 1998; Hoogsteder, 1996).Many institutions try to employ workers from ethnic minority groups,but they often experience difficulties in finding as well as keeping them.Attention is also being paid to intercultural management (Hoogsteder,1996). However, this process of “interculturalization” has as yet nothad a great impact on the way of working of most welfare institutions,and the development of intercultural methods for assessment and sup-port is still in its infancy (Bellaart & Ferrier, 1998; Commissie Marok-kaanse Jeugd, 1998).

A few residential youth care centers in the Netherlands have beenin the forefront of this development. They have been organized to serveethnic minority youth and their families in a culturally responsiveway. These relatively small specialized centers differ from the regularcenters in the following ways:

• they serve only ethnic minority clients (from one or more specificethnic or religious groups);

• most professionals working in the centers have an ethnic minoritybackground;

• in their method of working with youth and families they considerthe clients’ cultural background and bicultural reality;

• males and females (if present) are housed separately when tradi-tional culture requires this;

• objects and decorations from the children’s cultural background canbe seen in the institution;

• religious food proscriptions, celebrations, and norms are respected.(Ligthart & Cherabi, 1995; Sociaal-agogisch Centrum het Burger-weeshuis, 1996; Suir, 1997; Top, 1988; Wouda & Mateman, 1992)

Following the theoretical notions above, one would expect that thespecialized centers are very successful in terms of treatment outcomes.However, clients drop out from the care process in specialized as wellas in regular centers. We will show how this may occur by presentingthe case of a Moroccan boy who was taken into a specialized center.His case was the first of a larger research project on Moroccan youth

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in residential care in the Netherlands. In this qualitative study weconcentrated on Moroccans because of the marked cultural differencesbetween large parts of this group and the Dutch majority population.Furthermore, relatively many Moroccan youth and their families expe-rience difficulties in Dutch society and come into contact with thewelfare and justice system (Eldering, 1998; see also Brouwer, 1997;Eldering & Knorth, 1998; Simsek & Van Loggem, 1992; Van Gemert,1998; Werdmolder, 1990).

Our study focused on the explanatory models of clients and profes-sionals, particularly their perceptions of the current problems, theircauses, and the most desirable treatments or solutions (compare Adri-ani, 1983; Kleinman, 1980). One of our research questions was whetherand how differences in EM influenced the care and support process.Data were collected through open-ended interviews with youth, youthcare workers, parents when possible, and through the examination ofcase files. The interviews took place about two weeks after the youthhad entered the youth care center and again about three months later.The study was carried out in regular centers with a varying proportionof ethnic minority clients as well as in specialized centers helping onlyethnic minority youth. Seventeen girls and boys were involved, aged14 to 19. To aid the analyses, within-case and cross-case analyses wereused, as proposed by Miles and Huberman (1994). Below we will presentour within-case analysis of Rachid.

The Case of Rachid

Rachid (a fictional name) was 17 years old and the eldest son of aMoroccan family, consisting of, beside himself, his father and mother,his elder sister, and a number of younger siblings. The parents emi-grated from the north of Morocco, where they had received very littleeducation. His father came to the Netherlands in the late 1960s as a“guest worker,” followed by his second wife a few years after theirmarriage. All their children were born in the Netherlands. Both parentswere deeply religious and dressed in traditional Moroccan style. Thefamily lived on a welfare benefit, and the father regularly sent moneyto Morocco to support his first wife, to whom he was still married(polygamy is still allowed by Moroccan family law). The parents werenot proficient in Dutch and their social network consisted mainly offamily members. In contrast, Rachid had an ethnically mixed circle offriends and felt he was living “between two cultures.” Religion wasimportant to him but he found it hard to live up to his father’s expecta-tions regarding prayer and setting a good example to his siblings.

Rachid entered a specialized center for Moroccan boys after he had

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spent a short time in a center for juvenile delinquents. In this special-ized center most of the professionals were Moroccans. The center fol-lowed Islamic rules regarding food and the observance of Ramadan.The Moroccan workers often spoke Moroccan-Arabic in the group aswell as in their contacts with the parents. Parents were either visitedat home or were received in a room in the center that was furnishedand decorated in Moroccan style.

During his stay in the center the youth care worker who had firstbeen assigned to Rachid left and was replaced by a colleague. Bothmen were Moroccans who had been educated in the Netherlands onthe subject of social-educational work.

EMs Shortly After Entrance to Care

In our first interview with Rachid he said that he had been in youthprison as a result of a false accusation by his father of threatening himwith a knife. According to Rachid nothing like this had ever happened,although he admitted that there had been arguments between hisfather and himself over the money he earned from his job. His fatherthought Rachid should give his earnings to him. In the last of thearguments Rachid was verbally aggressive, which he later regretted.He believed that this incident led his father to go to the police with aninvented story “to get rid of him.” Rachid believed that his father didnot understand him because his father had been raised with Moroccanvalues and norms, while he, Rachid, had to deal with both Moroccanand Dutch culture in the Netherlands. In other words, he explainedthe problems by a difference in acculturation. Another cause he de-scribed was the fact that his large family had very little income. Rachidwanted to solve the problems by giving in to his father’s demandsregarding his salary. He also expected that the professionals in thecenter would speak with his father to bring about a reconciliation sohe could go home.

In contrast to Rachid, his father and mother told us about his regularverbal and physical aggressiveness toward all family members, includ-ing his parents. Surprisingly, the mother told us that the last incidentbefore the police took Rachid away was an act of aggression towardhis sister in the absence of his father. Some misunderstanding seemedto be in play. The parents attributed Rachid’s behavior to the tempera-ment he had inherited from his father and added that the father hadspoiled his eldest son. The father hoped that the workers in the centerwould tell Rachid to obey and respect his parents and wanted him tocome home. However, he was not sure the professionals would do this.Similarly, he hoped that the professionals observed the Islamic pro-scriptions but did not trust their information that this was the case.

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The youth care worker was convinced that Rachid had in fact threat-ened his father with a knife. He believed that the boy would not admitthis because threatening your father was considered shameful in Moroc-can culture. The professionals planned to speak with Rachid’s fatherabout re-establishing contact with his son and to explain to both thatconflicts could best be solved by discussing them. The youth care workerwanted Rachid to think about his own behavior and change it. His firstimpressions of Rachid’s behavior in the center were favorable, as heappeared calm, independent, and motivated to solve his problems.

Developments in Behavior and Clinical Communication

In the second interview the new youth care worker reported that thecalm conduct of Rachid changed after a few weeks in the center. Firstof all, a conflict emerged between him and the youth care workersabout his salary, which was similar to the conflict he had had with hisfather. Secondly, he protested against his new youth care worker, whohad written a critical observational report about him. Furthermore, itbecame increasingly clear that it was hard for Rachid to solve conflictswith other youth by discussion instead of aggression. The youth careworker tried to teach him to negotiate in these situations and did hisbest to give Rachid some insight into his own problematic behavior.This resulted in some improvement. However, the youth care workerfelt that Rachid believed he did not need any more help and that hedistrusted the professionals.

After the first few meetings between the professionals and the par-ents in the first month of Rachid’s stay, little communication took placebetween them. The father once cancelled an appointment because itinterfered with his prayers, and further contact was only maintainedby phone. These contacts mostly concerned evaluations of home visitsof Rachid. Besides the center, a few other organizations for social workmaintained contact with the parents.

EMs Several Months After Entrance to Care

More than three months after Rachid entered the center he told usmore about his previous conflicts with his father regarding his father’srules. During the home visits from the center, however, everythingwent well. With respect to the causes of the problems, Rachid said thathis father had sometimes used a curse on him in the form of a prediction,of which “I hope you will go to prison” actually had come true. He didnot agree with the statement in the observational report that he couldnot accept his father’s other wife. Rachid wanted to go home becausethe problems seemed over, although he realized some guidance would

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still be needed there. In contrast, several professionals had advisedhim to go to another center where he could learn to live on his own.He decided to give in to them so that he could leave the present center,where he felt bored and believed he could learn nothing.

The second parent interview was held with the mother in the absenceof the father, who was in Morocco. Her story about the problems wasstill the same, but she said that no conflicts occurred between Rachidand his family during home visits. She now mentioned a supernaturalcause for the problems. According to her, the problems had startedafter Rachid’s return from a trip to Morocco. She believed that herhusband’s first wife had used magic to change Rachid and disrupt thefamily and she wanted to take her son to a traditional healer in Morocco(fqih) to solve the problem. She had informed the social worker of herideas by phone, who had said that she may try it.

In contrast, as a result of his observations of Rachid in the center,the second youth care worker did not believe the reports that everythingwent well during home visits. He believed that Rachid had regularconflicts with his father. He presented an elaborate theory in whichthe lack of pedagogical competencies of the parents, as well as theschools, and the unfavorable socioeconomic conditions of the familyplayed a role. The cultural mismatch between the Moroccan parentsand the Dutch context was an important element of this theory. Lookingat the way in which the problems could be solved, the youth care workerbelieved there was a lack of insight and real interest of the fatherregarding his son. The youth care worker did not believe that the fatherwould be able to change his behavior toward Rachid because of his age.Therefore, his advice to Rachid was to maintain contact with his familyand go to a center where he could learn to live on his own. In themeantime, Rachid was advised to learn to solve conflicts with wordsand acquire skills to become more independent.

Systematic Comparison of EMs

Table 1 displays a “concept-by-role-by-time” matrix (Miles & Huber-man, 1994) that shows the extent to which the (expressed) views ofRachid, his parents, and the professionals changed and the discrepanc-ies that emerged in the course of the first four months of Rachid’s stayin the center. The table shows clearly that after several months of carethe EMs of Rachid and his parents on the one hand and that of theyouth care worker on the other differed with respect to the problems,the causes, and the solutions. In spite of the youth care worker’s at-tempts, he was not able to overcome these differences. According toKleinman’s theory these increase the risk that clients will drop out ofthe care process.

Table 1Explanatory Models (EMs) in the First Four Months of Placement in Residential Care; The Case of Rachid

Time 2–4 Weeks After Entrance to Care 14–15 Weeks After Entrance to Care

EMrespondents EM youth care EM youth carerelated to EM youngster EM parent(s)* worker EM youngster EM parent(s)* worker

Central incidental aggres- regular aggressive regular aggressive same as before, same as before; re- same as before; re-problem sive behavior to- behavior toward behavior toward fa- plus former con- cently no problems cently more prob-

ward father in re- all family mem- ther; good behavior flicts with father at home lems in group andaction to conflict bers in group about rules; re- still problems atabout money cently no problems home

at home

Causes lack of understand- aggressive disposi- no ideas as yet hints at a super- (mother): super- pedagogical failureing by father as a tion inherited from natural explana- natural (magic out of father; failure ofresult of accultura- father; pedagogi- tion: curse of jealousy); peda- school; social envi-tion differences; cal failing by fa- gogical failing by ronment; bad socio-low income (socio- ther (spoiling) father (spoiling) economical pos-economical factor) ition

Treatment/ the center as go-be- (father): the center the center as go-be- going home with (mother): taking same as before,solution tween to re-estab- should tell his son tween to re-estab- guidance, or, if nec- youngster to Mo- plus becoming

lish contact with to change his ag- lish contact; young- essary, to another rocco to visit a tra- more independentparents; giving in gressive behavior; ster should develop center; in the pres- ditional healer**; and going to an-to father regarding youngster should insight into his ag- ent center there is the youngster may other centerpayment of salary; come home after gressive behavior nothing to learn either come homegoing home some time and change it or go to another

center

*If a view is known to be specific to one parent this is indicated between brackets.**Rachid’s mother has probably held this view for a longer time, but did not speak her mind in the presence of her husband during the first inter-view.

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Shortly after our last interview Rachid started to disobey the center’srules more and more often, and he was expelled six months after hisentrance. Since both Rachid and his father still preferred that Rachidgo back home, the guardianship organization involved gave in to theirwishes, and he went home. Instead of effecting a lasting change inRachid’s views, it seemed that clinical communication had increasedhis aversion to the professionals, resulting in his desire to escape fromthe center in one way or another.

Discussion

The case we have just presented shows that even in a specializedcenter with a relatively high level of cultural responsiveness, largediscrepancies can occur between the perspectives of Moroccan parentsand Moroccan professionals. The differences seem to have been relatedto the differing world views and clinical realities of the parties, whichmay have been influenced by differences in education between theilliterate parents and the educated professionals. Moreover, althoughclinical communication was facilitated by the fact that both parentsand workers spoke Moroccan-Arabic, mutual distrust impeded the careprocess.

Our findings that discrepancies between EMs occurred between pro-fessionals and clients at different times in the care process and thatEMs changed over time confirm Kleinman’s theory. We also found thatduring clinical communication, different strategies, aimed at differentends, were employed by professionals as well as clients. Giving in tothe professionals’ advice seemed to be Rachid’s strategy for escapingfrom the center. In the end, however, he found other ways to get hisown way. The case therefore also corroborates our hypothesis thatdiscrepancies between EMs and a failure to overcome them contributeto dropping out of the care process. As drop-out rates from residentialcare are generally high, varying from 15–40 percent (see Madge, 1995),our findings suggest that more attention be devoted to differences ofopinion between clients and professionals and to ways to overcomethese differences. Other authors in this journal have made similarrecommendations for the field (see Hoskins, 1999; McNown Johnson,1999). At the same time, this case shows that when a youth’s conductgets out of hand, a specialized center, just like a regular one, may reachthe point at which the only option left is to send him away (see Knorth &Smit, 1984).

With regard to the study itself it has become clear that the elicitationof the whole EM of clients is difficult for professionals and researchers.Although we followed the principles set by Kleinman, for example,

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interviewing parents at home with a neutral interpreter, a number offactors, be they cultural or psychological, may impede their telling thewhole story. One of the striking features of the case presented here isthe underlying conflict between the two wives of Rachid’s father, andmother’s reluctance to talk about this in the presence of her husband.As a result we can not conclude that the parents’ views have changedbetween time 1 and 2. Rather, we have gained additional informationduring the second interview. Triangulation in part helps to solve thesekinds of research problems (see Weiss, 1994).

Other cases showed us that, as Kleinman has warned also, an EMformed by a professional is not always in the same way or to the sameextent transmitted to the client. For instance, youth could not alwaystell what their youth care worker’s views were. There may be goodreasons for a professional to act in this way, for example, not to jeopar-dize a trusting relationship (see Ruijssenaars, Schoorl & Van der Ploeg,1995). However, this implies that an open exchange of views betweenclients and professionals, with a clear outcome in terms of shifts inEM, cannot always be expected.

Endnote

1. Defined as either born outside the Netherlands or in the Netherlands, with at leastone parent born outside the Netherlands.

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