Case Conceptualization

Presenting Problem

Jing (Lina) Zhang is a 16-year-old female in grade 11. She attended the counseling session

alongside her mother Sheng (Lilly) Li Zhou. Lina was referred by Dr. Smith from the Alberta

Family Wellness Walk-in clinic, due to concerns regarding family conflict and Lina’s high level

of stress and possible symptoms of anxiety in relation to school.

Predisposing Factors

The family consists of Lina, her mother, Lilly, and her father, Yuan Xiao (David), Zhang.

They immigrated from Hong Kong in 2010 to Calgary due to concerns of Hong Kong returning to

Chinese Rule. The family owned a successful retail business back in Hong Kong which helped

facilitate their Canadian citizenship and immigration process. However, the family business was

less successful in Calgary, leading to David getting a job (Forensic accountant) and Lina staying

at home.

While growing up Lina met her developmental milestones. She had her tonsils removed at

10 years old. She experienced menarche at age 12. She also appears to be in good health (in terms

of height & weight for her age/gender), no known allergies and her immunizations are up to date.

Precipitating Factors

According to Lilly, Lina’s mother, there has been escalating parent-child conflict since the

beginning of grade 9 or 10. According to Lina’s parents, there has been a history of disagreement

on household rules and bedtime routines.

The high school teacher/guidance counselor has shared that they are concerned about

Lina’s functioning at school. While Lilly’s main concern is the family conflict, she explains she is

also concerned about Lilly’s elevated worry regarding her school performance. Lina disagrees with
this, expressing that she is not concerned about school, but experiences stress when in conflict with

her mother about school. She has also explained that her reason for attending counseling was due

to her mother wanting her to go.

Perpetuating Factors

Lina is not sleeping and is highly focused on her ability to perform at school. She has

developed a routine of waking up at 2:00 am, doing homework until 4:30 am and returning to bed

until 6:30 am.

Lina continues to experience recurrent thoughts and ruminations related to failing, with an

on-going fear of school-based performance related to not getting sufficient grades, and academic

evaluation by teachers or peers.

Lina explains that she does not feel understood by her mother/parents in relation to her

need to be successful in school. The conflict between Lina and her mother often occurs when Lilly

attempts to encourage Lina to do activities outside of academics including going to bed or eating

dinner with the family. It is known that the ongoing conflict began when Lina was in grade 9 or

10 and it was around this time Lina stopped attending church, which acted as a recurring family

activity.

David, Lina’s father, continues to work long hours to support the family and does not get

directly involved in parenting efforts. Despite the ongoing conflict; both Lina and her mother

expressed hopes for therapy. For Lina, she is hoping for her mother to understand her more and

Lilly expressed that she wants the conflict to be reduced and her daughter to worry less about

school.

Protective Factors (strengths)

 Initially, Lina was reluctant to engage in counseling, but due to concerns of ongoing parent-

child conflict, she agreed to attend the counseling center for an assessment. Both Lina and her

mother noted the importance of attending counseling appointments in a manner that did not

interfere with school attendance. The family has some extended family in Calgary and Edmonton,

including Lilly’s elder sister, who they celebrate holidays with. The family also returns to Hong

Kong every second year to see family. Lilly and her husband have a strong connection to their

cultural community which includes attending church weekly.

Lina has a history of strong academic success, averaging 90’s across courses in elementary,

junior and high school. Lina is a member of the badminton team at school and has a level 8

certificate in piano which she practices on weekends. In addition, Lina also volunteers at the

hospital 2 times per week. Lina has expressed a goal of attending medical school. Lina’s mother

has been very supportive of these academic and non-academic achievements and has attempted to

help Lina become more balanced in terms of her focus on school work. Lilly is strongly supportive

and involved in her Lina’s life, she drives and picks her up at school daily. The family is doing

well financially and there are no concerns related to health, and no history of medical or mental

health concerns in the family. There is no indicated presence of psychotic, manic or hypomanic

symptoms. Lina is not currently taking any medication besides nutritional supplements, such as

Ginko Biloba and Omega-3 Fatty Acids and there are no issues of substance abuse.

Clinical Impression/Treatment Plan

There seem to be a Parent-Child Relational Problem between Lina and her family

(American Psychiatric Association, 2013). For example, the family has been having conflict

resolution difficulties for the past two years and it is to the point that the ongoing conflict has

significantly impaired the family’s daily functioning and thus requires some form of intervention.
 As noted earlier, this family immigrated from Hong Kong in 2010. Situating immigrant

families in the context of their cultural background, and migration experience allows us to better

understand the impact of immigration processes on families (Clark et al., 2009). While this family

immigrated 9 years ago, this is an important aspect for the clinician to bear in mind for therapy,

support, and connection to community resources which is relevant to the families’ context. Family

processes can change with immigration due to the shift in socio-cultural contexts (Buriel and De

Ment, 1997, as cited in Dyson, Wang, & Qi, 2012). Applying a cultural lens to this family is

important to avoid imposing common strategies used for Canadian born families. Further, paying

attention to how the past migration process may impact current familial relationships and

processes, is critical to developing a compatible treatment plan. Migrant families of Chinese

background may differ in their family functioning to Caucasian non-immigrants and North

American society in terms of cohesion, personal growth, and systems maintenance (Dyson, Wang,

& Qi, 2012). It should be noted, while not generalizing, that Chinese-American families value

education, hard work and discipline and Chinese immigrant parents in the US were reported to

stress the importance of school achievement and necessity of science-related career aspirations

(Zhou, 2009, & Li, 2004). It is important for the clinician to consider these factors while accounting

for the uniqueness and diversity among families.

Therefore, ultimately working alongside the family to understand their perspectives and

realities should be at the forefront of the treatment plan, with a consideration of their unique

experiences.

Individual and Family Therapy

It is understandable for Lina to feel some pressure regarding school performance and

university prospect given she is in grade 11. However, the pressure is to the point that both Lina’s
mother and her counselor are concerned for her overall wellbeing and believe there is a need for

professional help. In recognising Lina’s constant worrying and anxiety-provoking thoughts it is

suggested that this treatment plan involve individual therapy for Lina, using Cognitive Behavioral

Therapy (CBT) that can support Lina in recognizing unhealthy thinking patterns (Dobson &

Dobson, 2016).

Collaborative Family therapy is suggested for Lina, her mother and father to address

communication barriers and relationship difficulties (Anderson, 2012). It has been noted during

previous sessions that David works long hours and has not been involved in direct parenting.

Addressing this gap in therapy sessions could work to strengthen parenting approaches and

develop a cohesiveness between family members. Family therapy can also support Lilly's hope to

reduce family conflict. Considering David's long working hours, and Lina’s involvement in

school/volunteering, flexible therapy times, sessions and goals should be developed accordingly.

Connection to cultural and community resources

Lilly had explained that Lina stopped going to church with the family in grade 10.

Considering that David and Lilly have expressed a strong cultural connection to their community,

this aspect should be considered in the treatment plan. Inquiring about pre-existing connections to

cultural community centres should be explored. Connections to the cultural community should

take into consideration youth programs, that can allow Lina to connect and further build

friendships within her cultural community.

Continued communication with Lina’s teacher/guidance counselor

A continuation of regular meetings between Lina’s teacher/guidance counselor and her is

suggested. An additional Strengths and Difficulties questionnaire should be given to Lina’s teacher

to further evaluate progress.

 Evaluation

To evaluate the effectiveness of these approaches, the clinician would need to work

collaboratively to determine how many therapy sessions are needed to ensure progress is being

made and to recognize any changes.

Lina and Lilly have both agreed to come to therapy session provided it does not interfere

with Lina’s school attendance. Exploring other potential barriers that may impede the family from

attending therapy sessions should be considered. Some of these potential barriers may include

David long working hours to provide for the family financially, Lina’s school expectations, and

the family’s strong connection to their cultural community.

After determining the number of sessions required, continuing to use the Strength and

Difficulties Questionnaire (SDQ) is suggested. This can be done by having Lina, her parents and

the teacher/guidance counselor complete a second questionnaire at an agreed upon time between

the clinician and the family. This questionnaire will assist in assessing Lina’s progress by

comparing to the initial questionnaire. This is to evaluate Lina’s recurrent stressful thoughts and

challenges, behavior, and routine with regards to family functioning.

Summary

Overall, as expressed by the family, this treatment plan will work to decrease family

conflict, increase Lina’s well-being and develop an overall healthier family functioning among all

members. This family demonstrates various strengths in the adaptation to immigrate to Canada,

Lina’s academic success, and the support they provide each other through this process. Identified

hopes by Lina and her mother suggest a promising outcome. By working collaboratively with the
Lina and her family the clinician can develop a relevant treatment plan that can work to improve

overall family functioning and Lina’s well-being for the future.

 References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders

(DSM-5®). American Psychiatric Pub.

Anderson, H. (2012). Collaborative relationships and dialogic conversations: Ideas for a

relationally responsive practice. Family Process, 51(1), 8-24.

Clark, R. L., Glick, J. E., & Bures, R. M. (2009). Immigrant families over the life course: Research

directions and needs. Journal of Family Issues, 30, 852–872.

doi:10.1177/0192513X09332162.

Dobson, D., & Dobson, K. S. (2016). Evidence-based practice of cognitive-behavioral therapy

(2nd ed.). New York, NY: The Guilford Press. (Chapter 11, pp. 232-250).

Dyson, L., Wang, M., Qi, J. (2012). At the interface of ethnicity and recent immigration: Family

functioning of Chinese with school-age children in Canada. Journal of Child and Family

Studies, 22, 1061-1073.

Li, J. (2004). Parental expectations of Chinese immigrants: A folk theory about children’s school

achievement. Race Ethnicity and Education, 7, 167–183.

Zhou, M. (2009). Contemporary Chinese America—immigration, ethnicity, and community

transformation. Philadelphia: Temple University Press.