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Markkula Center for Applied Ethics

Delinquency or Mental Health Problem?

The Case of Pablo Sanchez

Karen Peterson-Iyer

At 15, Pablo Sanchez is already enmeshed in the juvenile justice system. Now he is also becoming immersed in the county mental health system.

Pablo is a member of a large extended family in a medium-sized city in California's Central Valley. Crossing the Arizona/Mexico border on foot, Pablo's mother immigrated illegally to the United States from her small Mexican village, along with her four children, when Pablo was ten years old. She was primarily looking for a better life for her children and for herself. The trip itself was arduous, and Pablo and his siblings don't often talk about the physical exhaustion, thirst, and intense fear that characterized that journey. Pablo's father, who was in prison in Mexico at the time, remained there until he was killed a year later. (Since the family does not have documentation and therefore lives illegally in the United States, neither Pablo nor his mother or siblings were able to travel back to Mexico for the father's funeral.) Pablo's mother works as a maid in a local motel and struggles to put food on the table for her family. Pablo has three siblings: an older sister, now 18, and twin younger brothers, age 8. Pablo's sister, who works sporadically in a fruit-packing plant, is studying at night for her high school GED.

After coming to the U.S., Pablo and his siblings quickly became bilingual but speak with accents. Their mother, however, continues to speak only a few words in English and prefers to communicate in Spanish, something that embarrasses and often irritates Pablo.

At age 11, when Pablo entered middle school (and shortly after the death of his father in Mexico), his mother and older sister noticed a marked increase in his general anger level and emotional distancing from the rest of the family. He began having trouble sleeping and concentrating in school, and his class conduct grew increasingly disruptive. His grades dropped, and he began drifting away from his friends. After speaking with several of her close friends and older relatives, Pablo's mother attributed his behavior to "nervios"—fear, anxiety, and anger brought on by stressful life circumstances. She hoped that the symptoms would ease with time and prayer. In addition, Pablo's mother sought help from a local Mexican herbalist who prescribes a variety of calming herbal remedies for Pablo's behavioral problems.

Shortly after Pablo turned 14, in the ninth grade, he became connected to a gang active at his large high school. He began to experiment with alcohol and marijuana, soon progressing to cocaine and methamphetamines. On several occasions he was suspended from school for days at a time. The school counselor repeatedly tried to reach Pablo's mother to discuss his situation with her, but Pablo's mother was usually at work when the counselor called and had a great deal of difficulty navigating the school's phone tree and answering system in order to return the calls in the evening. Eventually the counselor sent home written communication, in English, which Pablo's sister attempted to translate for her mother.

Pablo's mother grew increasingly worried about her son. At first she addressed the problem by insisting that he stay home in the afternoons and care for his younger brothers (while she was at work), since he was the closest thing to a "father" they had; but Pablo began instead to take his siblings with him to meet his friends, which upset his mother even further. One day Pablo came home with a tattoo on his hand identifying him as a member of his gang. His mother, beside herself with worry and anger, insisted that he stop seeing his new friends altogether. Pablo laughed at her, mocked her (in English), and even made a threatening gesture and offered to "show her" who was "the real leader" of the family. He spent that night at a friend's house; the next day when he returned home, his mother was relieved and gratified to have him back. These patterns continued for several months, at times escalating as Pablo spent more and more time with his new friends. On several occasions he landed in juvenile hall for petty drug and other offenses.

During Pablo's most recent encounter with the juvenile authorities, Pablo met a county social worker who took an interest in him. Suspecting that his history of poor concentration, irritability, and oppositional conduct might mask deeper issues, she referred Pablo to a county-supported therapy program for juvenile offenders. As part of his probation agreement, Pablo was ordered to make weekly visits to a therapist at the county-affiliated mental health clinic.

With some difficulty, Pablo's mother rearranged her work schedule so that she could accompany Pablo to his first meeting at the clinic. When they arrived at the reception area, the somewhat harried receptionist told them rather brusquely to "sit down and wait over there." Pablo, visibly irritated, slumped in the chair next to his nervous mother. Thirty minutes later, a middle-aged white counselor emerged and instructed Pablo and his mother to follow her into a small, dark meeting room down the hallway. There she informed them (in English) of her name and that she had reviewed Pablo's case file from the county. She asked Pablo directly whether he was currently using any drugs, to which Pablo muttered a simple "no." She went on to ask him what drugs he had used in the past, and for how many years. When Pablo's mother offered that she frequently gives Pablo doses of herbal tinctures, the counselor wrote it down furiously, with a hard expression on her face. After about ten minutes, the counselor switched into passable (if imperfect) Spanish, telling Pablo's mother that this was purely a short intake interview, but that she would be able to offer Pablo one hour per week of talk therapy, paid for by the county, and potentially referring Pablo to a psychiatrist if a need for medication arose. She advised his mother immediately to discontinue any herbal treatments. Unsure as to whether or not she fully understood what the counselor was offering, Pablo's mother nevertheless agreed and promised that Pablo would come back to see her again. Pablo himself appeared angry and taciturn.

Pablo did in fact return to the counselor the following week and for several weeks thereafter, in spite of the fact that he resented his probation officer's insistence on it. But he did not develop a sense of rapport or trust with the counselor, and his participation in the sessions was grudging.

After two months of meeting with Pablo, the counselor does not feel that they are making significant progress. Although she agrees with the juvenile social worker that Pablo's anger and concentration issues may be related to deeper, unaddressed issues, the counselor has failed to achieve the level of trust with Pablo that would have allowed her to explore the matter further. Additionally, Pablo's counselor is irritated with the frequent (three to four times per week) phone calls she now receives from Pablo's mother, inquiring about the content of the sessions and about her son's overall progress. The counselor believes that Pablo's mother is inappropriately "enmeshed" with her son, thus fueling his desire to differentiate from his family by connecting with his peers in the gang. She believes that Pablo needs to take responsibility for his own health and well-being. Pablo's mother, supportive of the counseling at first, is growing increasingly opposed to it as the weeks pass by with little improvement in her son's behavior and attitude. She fundamentally does not trust the counselor and wonders if Pablo's growing talk of becoming more "independent" from his family is in fact driven by the counseling sessions themselves.

How could this situation have been handled in a more "culturally competent" manner?

Reflection by Thomas Plante

Introduction to Culturally Competent Care

An Introduction to Culturally Competent Care in the Latino Context

Karen Peterson-Iyer is program specialist in health care ethics at the Markkula Center for Applied Ethics.

Apr 1, 2011

Patient and doctor