Negotiation of gender responsibilities in resettled refugee populations through Relationship Enhancement training

Traditional gender responsibilities and displacement

Currently, the largest incoming refugee populations in the United States are from Africa, the Middle East, and South and South East Asia. ³ They represent sociocentric, or collectivistic cultures, in contrast to the dominant western European individualistic culture of the U.S. These groups traditionally have a clear division of gender roles and responsibilities learned through socialization. The roles are set, maintained, and reinforced by ethnic practices, language, and external pressures from the extended family and community (Brown, 2006; Krulfeld, 1994; Ting-Toomey & Chung, 2005). Refugee couples often come from one of three economic circumstances: (a) the woman served the role of a stay-at-home wife and/or mother while the husband worked; (b) both worked and the wife also ensured the responsibilities inside the home were met with the support of family, friends, and neighbors and domestic help; or (c) neither worked, but the woman maintained the responsibilities of taking care of the home and family. Within the identified groups, the male’s role is that of primary breadwinner, protector, and family representative for matters outside of the home; in contrast, the female’s role is that of primary homemaker, nurturer, caretaker for the children, and manager of household activities. For the purpose of this article, gender roles and responsibilities will refer to the traditional division of labor between the sexes.

Civil strife, war, and persecution can disrupt the family system as displaced populations lose their physical, financial, and emotional supports. Spouses may not be able to fulfill their responsibilities due to separation, disability, or death. Existing economic opportunities may be eliminated. Future income may be limited to the informal economy if the country of asylum does not grant the right to work or discriminates in hiring practices. Families may be separated from their support systems that provided women benefits such as childcare, care of sick children, and help with cooking and household management. Despite the duration of disruptive conditions, ideas regarding gender responsibilities may still be ingrained in the culture of many individuals. When refugees are resettled to an individualistic society, which values a more equal division of labor, challenges to the family system will arise. The power structure of the couple system may need to change to conform to the requirements of their new environment and goals (McLean, 1999).

Impact of cultural adaptation on marital gender roles

After resettlement, refugee families must learn to become self-sufficient and manage their new opportunities and finances as quickly as possible. If the woman begins working, either as the sole provider or to increase the family income, or if the welfare benefit checks are issued in her name, there may be a challenge to the traditional beliefs regarding her roles and responsibilities. Some women who had worked for pleasure in their home countries (Crosby, 2006) must now work to contribute to the family income. Whether real or perceived, the changes may be challenging, threatening, or even overwhelming to the marital unit. Without a change in expectations, or a renegotiation of responsibilities, an employed woman may remain fully responsible for taking care of the children, cleaning the home, and cooking the meals.

In contrast, a husband may remain responsible as the sole provider despite any barriers to employment. He may struggle to learn the language, prove his education and credentials, or deal with the shame of taking lower skill jobs. Men may experience additional challenges to their gender identity when their employed wife needs their help with the household and childcare responsibilities. One Karen refugee from Burma resettled to North Carolina expressed (after participation in the RE program) “Back at home, I didn’t do work around the house, that was my wife’s job.” A husband may refuse to help with housework or childcare. He may become depressed or frustrated as a result of his own unemployment and his wife’s changing status (Potocky-Tripodi, 2002). Maintaining authority may preoccupy men as they watch the changes that challenge gender and parent roles (Ooms, 2007). Men are often threatened by the presumed increase in women’s rights, fearing their wives can become self-sufficient, no longer needing them. At the same time, their wives may welcome the new employment opportunities. Or they may be distressed about working, challenging gender roles, or putting their children in daycare to be watched by strangers from outside her culture. Both men and women may become preoccupied with avoiding changes and fear the unknown. Or they may want to welcome the change, but not know how to manage the change without upsetting their partner. Furthermore, they may be considering what the consequences of the changes and the loss of status may have on their social position in the local or diasporic communities and their country of origin.

These changes can impact not only marital adjustment, but also the couple’s mental health. Refugees may come with preexisting symptoms of mental illness or develop symptoms during the assimilation process. Their spouse may not know how to provide them support. If they are isolated, or preoccupied with their reputation, refugees may not be connected with, or willing to rely on, community members who have managed similar circumstances. In more extreme cases, they may be faced with a spouse that is unable to contribute to the family’s adjustment. Studying Bosnian refugees resettled in New York City and Vienna, Franz (2003) found some husbands had begun abusing drugs and alcohol. The men were focused retrospectively on the losses they endured during war. Yet, the wives appeared to embrace their roles as matriarchs and were focused on the future and keeping families fed and together. Women, who are less vulnerable to shame than men (Love & Stosny, 2007; Stosny, 2007), may be more willing to take risks, learn the language, and take a job that is low status and, or beneath their level of skills or education (Potocky-Tripodi, 2002). This may explain why Franz (2003) found that the Bosnian men had a harder time adapting to their new culture and held onto their national identities longer than did the women who were more focused on building a new life.

Changes and adjustment problems to new marital roles can create conflict, distance, and in more extreme cases, separation. As one Somali woman put it, “You can live without a husband”™(Crosby, 2006). Since it is now possible to earn her own living, a woman could be independent of her husband and support her family without him.

When refugees are resettled, it is important to consider their goals, how they are affected by new societal and cultural pressures, and the impact of changes on the division of labor. While it may be important to assimilate the expectations of the new cultural environment, it may be equally important to preserve aspects of one’s own culture for successful integration. Furthermore, drastic, or even minor, changes in roles may not be welcomed and may be perceived as a threat to the family system and individual identity (Crosby, 2006; Potocky-Tripodi, 2002). Typically, couples need to redistribute responsibilities of managing finances, childcare, employment, and parent–school involvement. Successful redistribution of responsibilities is dependent on communication and mutual understanding of each other’s situation, resources, limitations, and perceived threats to gender roles. Understanding is based on awareness and sensitivity to the other person’s verbal and nonverbal messages. Couples need to recognize each other’s new thoughts, concerns, desires, and feelings (Guerney & Ortwein, 2005; Guerney et al., 2007), and find ways to help the other with their stress. They also need to rebuild their internal and external support systems.

Relationship Enhancement theory

Relationship Enhancement theory, developed by Guerney (1977), presents a model for communication and problem solving which integrates psychodynamic, learning (behavioral, cognitive, social), humanistic, and interpersonal principles and methods within a skill-building framework (Accordino & Guerney, 2002, 2003; Guerney, 2005). The model is applied in psycho-educational and therapeutic programs that require skills training, practice, and supervision (Accordino & Guerney, 2003; Guerney, 2005). Research reveals RE’s immediate and sustained impact on communication and relationship satisfaction (Accordino & Guerney, 2003; Griffin & Apostal, 1993; Guerney, Vogelsong, & Coufal, 1983). The effects of RE not only are maintained in follow-ups of approximately a year (Griffin & Apostal, 1993; Waldo, 1986) but can become even stronger over time (Griffin & Apostal, 1993; Guerney et al., 1983).

The values of RE arise out of Carl Roger’s theories that individuals have within themselves their own capacities to resolve conflicts (Ginsberg, 1997). Conflicts can be best resolved in relationships when there is a context of safety, security, empathy, and acceptance (Guerney, 2005). As most incoming refugees are isolated from the support network of family and friends left behind, a couple’s ability to rely on each other and solve problems is integral to their success. Ginsberg (1997, p. 16) describes the RE values as “an atmosphere of non-judgment, acceptance, and the inherent equivalence among all human beings, no matter their role or place in hierarchy may be.” Guerney (2005, p. 7) presents the RE process as a way to help teach clients to “achieve coordination among their needs and goals and those of others in such a way that mutual satisfactions are maximized and pain and sacrifice are minimized.” Snyder (1992) identified that the application of RE gives opportunities to make profound changes in relationships between genders. RE provides a potential framework for refugees who are challenged by changing gender responsibilities and threats to hierarchy.

Development of the Relationship Enhancement for Refugees and Immigrants Program

This study arose from the application of the Relationship Enhancement model to refugee populations by the U.S. Committee for Refugees and Immigrants (USCRI) in a multisite demonstration project across seven states. The program was funded in October 2006 through a 5-year Refugee Healthy Marriage grant from the U.S. Department of Health and Human Services, Administration for Children and Families, Office of Refugee Resettlement. USCRI worked with the Institute for the Development of Emotional and Life Skills (IDEALS) to adapt workshop curricula and participant materials (Guerney & Ortwein, 2005) for a new program titled Relationship Enhancement for Refugees and Immigrants (Guerney, Ortwein, & Amin, 2007, 2008, 2009a, 2009b, 2011; Guerney, Ortwein, Amin, Chaterdon, & Solly, 2008). While preserving the process of the model, the language of RE was simplified, translated, and tested in culturally and linguistically diverse populations. A 24-hour curriculum was developed for psycho-educational group workshops that addressed stressors of acculturation and supported adaptation through the application of RE through three 8-hour workshops: Introduction to Relationship Enhancement (2007), Family Stress and Conflict Management (2007) and Relationship Enhancement and Financial Literacy (2008). Participant materials were also simplified and focused on the immigrant experience. The program was developed and administered by the author, and delivered through seven local not-for-profit refugee resettlement agencies: USCRI Albany in New York; USCRI North Carolina in Raleigh; Vermont Refugee Resettlement Program (USCRI) in Colchester; International Institute of Erie (USCRI) in Pennsylvania; International Center in Bowling Green, Kentucky; Jewish Vocational Services in Kansas City, Missouri; and International Institute of Los Angeles in California.

The adaptations of the curricula (Guerney et al., 2007) and participant materials (Guerney et al., 2008) were validated in the field by a team of seven full-time refugee and immigrant paraprofessional staff and one American-born licensed mental health professional, together with their local interpreters. Over the period of 2 years, through consensus in the field, the second edition of the participant materials (Guerney et al., 2009b) was developed and published, solidifying the adapted RE program (Guerney et al., 2007, 2009b). IDEALS participated in the adaptation process and approved existing changes and ensured fidelity to the original model.

The inclusion criteria for participation in the workshops were age (over 16), immigration status, and time in the United States. The program was restricted by the Office of Refugee Resettlement to the following populations that were eligible for services: refugees, asylees, Haitian and Cuban entrants, and holders of Special Immigrant visas, hereinafter referred to as refugees. Refugees who had arrived in the United States less than 6 weeks before the workshop were excluded from participation, allowing time for initial adaptation, as were those who were naturalized as citizens. Any individual who was identified as in a relationship with domestic violence was also excluded from participation, and referred for treatment. Those individuals were able to participate after they had demonstrated initiation of treatment. When screening was not possible until after the start of the workshop, referrals and follow-up for additional services occurred subsequently.

Relationship Enhancement workshops were delivered from February 2007 through September 2011. During this time, a total of 6,181 refugees completed the introductory 8-hour workshop: 3,482 individuals attended with their partner and 966 additional married individuals attended without their significant other. These individuals either did not attend or complete the workshop with their spouses, or had spouses who never participated in the program. The other categories were single men (n = 839), single women (n = 816), and youth (n = 78). Site staff documented marital status; however, workshops were open to singles, nonmarried couples, separated, divorced, and widowed individuals. No monetary incentives were offered for participation, except in limited cases, when bus tokens and daycare services were provided to facilitate access to the workshop. In total, clients from 30 different ethnic groups from Africa, Asia, Europe, and South America ⁴ participated in the program. All adult age groups participated including a small sample of youth over the age of 16. The literacy levels of participants ranged from illiterate in their native language, to written and spoken fluency in English. Participants’ backgrounds varied and included a background of rural agriculture, those born or raised in a refugee camp, and urban educated professionals. The categories of income level ranged from welfare benefits to dual income. This paper will focus on one common theme that arose from both couples and singles in workshops: challenges to gender roles after resettlement.

The Relationship Enhancement skills

The refugee program consists of 10 core RE skills taught consecutively: (1) “showing understanding” (listening and empathic expression); (2) “expression”; (3) “discussion” (structured dialogue); (4) “problem solving”; (5) “self-change”; (6) “helping others change”; (7) “conflict management”; (8) “coaching”; (9) “skill maintenance”; and (10) “generalization” to other relationships and situations. This paper will illustrate the first four skills taught in the initial 8-hour introductory workshop (Guerney et al., 2007).

The RE model consists of building skills of empathy and structuring dialogue, alternating the skill of empathy with expression of individual experience. The goal is to achieve what Scuka (2005) describes as “deepening dialogues” through empathy. Each person takes turns expressing their experience and shows their understanding of the other person’s experience. Through this structured style of discussion, a couple can go deeper into thinking about, discussing, and identifying both their own and the other’s core concerns. Once each person’s core concern about the issue or problem is identified, they are ready to proceed to problem solving. Figure 1 presents the skill components and illustrates the interaction in the RE process. Note the dashed outline of the arrow leading to “problem solving” skill. The dashes indicate that although a couple may think the core concerns are identified, a deeper issue may not have yet surfaced or been discussed. This may impede progress during any stage of application of “problem solving” skill in working out details. Or the planned solution may not lead to the desired results, indicating a need for additional skilled discussion. OPEN IN VIEWER

To achieve skill mastery and deep dialogues, supervision is provided by trained workshop leaders, interpreters, community leaders, or therapists. Until the couple is able to create this environment for themselves through demonstration of skill use and practice, supervised practice is indicated (Ginsberg, 1997; Guerney, 1977, 2005; Scuka, 2005). In supervision, the coach (either trained therapist or paraprofessional) uses the skills of prompting, modeling, and reinforcing to facilitate the process. The coach attempts to empathize throughout the process, in order to monitor the dialogue for accuracy and depth and be in synchrony with each member of the dyad. Through the expression and modeling of empathy, the coach can also “troubleshoot” to regulate the dialogue (Scuka, 2005).

To facilitate the moderation of the discussion, an object can be used to designate which individual is using the expression skill while the other person listens and expresses empathy. A soft squeezable ball was used in the program, which had an additional function as a stress- relieving object. The selected object and the illustrated workbook (Guerney et al., 2009a, 2009b, 2011) can be used by either individual, or the coach, to remind, prompt, and maintain skill use. The workbook (Guerney et al., 2008, 2009b), and translated editions (Guerney et al., 2009a, 2011) also serve as a visual aid and learning tool to communicate messages across languages and literacy levels. The linear presentation of the skills is combined with pictures that represent three different family compositions and ethnic groups from South East Asia, the Middle East, and the central African region. This aids indirect communication and learning through imagination and storytelling. This layout was designed to meet the circular style of communication common in sociocentric populations (Ting-Toomey & Chung, 2008).

Case example of Ram and Chandra

A case example will illustrate the application of the Relationship Enhancement model to negotiate gender responsibilities between husband and wife. The clinical vignette is both a demonstration of skill application and supervision. It was selected from a supervised practice during a RE workshop observation in 2009. A Bhutanese refugee couple was coached to discuss the wife’s concerns about managing her increased household chores while her husband spent significant time outside of the home. Refer to Figure 1 for an illustration of the RE process through which the couple was coached.

Ram and his wife Chandra (fictitious names to preserve confidentiality) were a young Bhutanese married couple in their mid-20s, with no children. They both were born in a refugee camp in Nepal after their families had fled Bhutan. They had a similar beginner’s level of English fluency gained in schools in the refugee camp. Two months after they had arrived in the U.S., they had completed the first 4 hours of the introductory RE workshop (Guerney et al., 2007) and learned “showing understanding” and “expression” skills. This observation took place one week later during the second 4-hour workshop.

The workshop leader had prepared the group with directions for practice and suggested topics such as managing gender responsibilities, parenting, and extended family relationships. Each pair was directed to identify and discuss an issue with “discussion skill.” They were allotted 25 minutes for practice in dyads. Once each person’s core concerns were identified, the group was given an opportunity to process and discuss their experiences. Afterwards, “problem solving skill” was taught and they were given an additional 25 minutes for practice time to agree and plan a resolution.

Although the workshop was translated into Nepali, the couple was able to practice the skills in English. When approached, they had practiced identifying the good about each other and begun discussing the topic demonstrated by the workshop leader. As that topic was not an existing issue, they were given additional ideas for topics to discuss. Finally, at the suggestion that they discuss a topic on which either might need help from the other, the wife earnestly volunteered. With a big smile, while looking into her husband’s eyes, she expressed that he always went out with his friends and she wanted more help from him at home. Chandra was praised for identifying an issue and asked to rephrase her concern without using the trigger word “always.” She listed the new daily chores she had to do to maintain their apartment. In response, Ram quickly agreed to help her and stay home. Ram was given appreciation for his willingness to support his wife and redirected to apply “showing understanding” skill. He was given the first couple of words to start: “for you Chandra, you.” As he expressed his empathy, Chandra began nodding, demonstrating that she felt understood. He then repeated his decision to stay home and help her. It was obvious in Ram’s verbal and nonverbal responses, in the way he looked at her and smiled, that he experienced a sense of urgency to make his wife happy. Ram was redirected to hold his desires to apply a solution and prompted to continue with the RE skilled dialogue process. He was then given a turn to express his own experience with the issue.

Ram told his wife that everything was “so new in America” and there was so much that he needed to learn. He explained that he was often out with his friends trying to learn, both from and with them, about life in America. He wanted to learn as much as he could in order to help his wife, so together they could be successful. Ram clarified that he was often at the resettlement agency, a social service office, or elsewhere, trying to take care of their new needs. He ended by repeating his decision to stay home for her. He specified that he would stay home in the afternoons and evenings. Ram’s effective use of the expression skill was reinforced by highlighting how well he expressed himself to his wife, used his own point of view, and gave specifics. Again, he was reminded to wait and follow the process of RE skills before stating a solution or starting problem solving skill. Chandra was then prompted to show understanding. As she expressed her empathy and understanding, she developed a new realization. Taking her turn, she expressed that she, too, needed to learn about America by going out with her friends. She described this thought with some urgency in her voice, nodding her head, trying to show that she identified with him through her new understanding. Without prompting, he used “showing understanding” skill and validated her new desires. With a large smile and widening eyes, Chandra appeared excited about this new understanding and connection with her husband.

After each person’s core concern was identified, and they had recognized a mutual need, Ram and Chandra were ready to move into the next stage and apply “problem solving” skill. To facilitate the process, they used a Problem Solving Steps ⁵ worksheet in their illustrated workbook. The worksheet is a visual guide for problem solving and provides space to identify each person’s core concerns, a general agreement that meets both core concerns, details of the agreement, plans for special circumstances, and a review date. Chandra’s core concern was that she wanted her husband home to help with tasks in their new home. Ram’s core concern was that he desired to provide for the family by learning as much as he could from others. He wanted to prepare the family to be successful in their new lives. Their mutual agreement, which met both of their core concerns, was to learn from others and work together as a couple to be successful in the U.S. As they moved on to work out details for an arrangement, Chandra only asked Ram to stay home one hour in the mornings and help. It was a request to which her husband readily agreed. They both agreed to spend time outside of the home to learn how to better support their family. They planned for special circumstances for when this plan would not work. They also set up a time frame to review their plan in intervals, at one week, two weeks, and one month.

Discussion

The vignette illustrates how Chandra and Ram were able to address changes in their marital relationship and find a mutually reasonable and beneficial solution that incorporated both of their concerns. Through the structured format, the couple took turns to express and empathize with each other’s experiences of thoughts, concerns, desires, and feelings. They were coached to discuss the issue in depth, from both sides, before making decisions or identifying solutions. With each step, they were able to go deeper and explore, identify, and express their conscious and subconscious experiences. They understood better not only their partner’s issues, but also themselves. Ram understood how much his wife needed him at home. Chandra realized how important it was for her husband to spend time outside of the home, and the supportive role of his friends. Even though Ram was not working, Chandra learned how he was still trying to provide for the family.

Through empathic listening and expression, mutual empathy was achieved. As they gained a better understanding of their mutual situation, another connection was created in the marital relationship. The mutual empathy led to mutual empowerment, enabling them to move forward. Ram no longer had to make an unrealistic promise to his wife to stay home every afternoon and evening. Through the RE process, they were able to negotiate and share in each other’s burden of providing for their family. They each found a way to contribute to the other’s traditional responsibilities.

Each member of the couple was also able to understand how the loss of their support systems affected them, both individually and jointly. While manifested differently, through the skilled discussion, the couple was able to see the mutuality of their situation. Both needed to establish a new network of friends and elders. Although, not directly discussed, their resolution focused on building their support system. Ram had to preserve and develop his new supportive relationships. These relationships provided camaraderie and continuity in their common values, something he had not found within the western community. Chandra knew few Bhutanese and had a new living environment. Her one-bedroom apartment was quiet, and at times lonely, compared with the one-room hut she had to share with her extended family. She watched her husband go out day after day to spend time with friends. Her sense of isolation combined with the increase in household tasks became a stressor for her. She yearned for her husband to be home more, to spend time with her, and ease her burdens of new household duties. Although she did not address core concerns of missing him, she did address her isolation through requesting more time with her husband and her friends. Ram’s rapid responses to help her may be related to his quickly sensing, understanding, and empathizing with her reality. With additional skilled dialogue, Chandra may be able to further express her feelings of isolation. Ram could continue to share the pressures he feels while trying to provide a new life for them in the United States.

The RE process also provides a way for couples to access each other’s strengths. When they are able to explore and express their deeper core concerns as well as understanding their partners, the internal resources for a solution can become clearer. Ram’s strength was courage and determination to tackle his unknown environment. He was dedicated and committed to his family’s future. This became clear to Chandra after she felt understood and when she tried to understand his experience. Only when Ram was given an opportunity to express himself, did he reveal that he was working hard for their benefit. She quickly realized his assets and wanted to not only preserve them but also learn from him. Her strengths and capacity to support her husband surfaced with a new commitment and a reasonable expectation of change.

Regardless of what felt uncomfortable, challenging, and, or confusing, the role of the coach in combination with the rules of dialogue, allowed a structured and safe environment for discussion. When the coach sensed Chandra’s workload and loneliness, it was predicted Ram may have had a similar empathic response by the way he quickly, and repetitively, responded with potentially unrealizable solutions. Furthermore, the coach sensed and consequently appreciated Ram’s caring and commitment to alleviate his wife’s stress. Transference may have also affected the situation, as Ram may have wanted to save face in front of the outsider. Ongoing empathy towards clients allows a nonthreatening approach and opportunities for differing strategies to support the couple through the process. It also slows down the process allowing time for empathic understanding, appreciation, and identification of the presenting strengths.

Challenges in training of the RE model

There was some initial hesitancy from workshop leaders to introduce what appeared as a fairly egalitarian process. There were fears that the marriage education program would present another challenge to traditional beliefs, in an already too stressful environment that required many changes including acculturation. It was also feared that for people from many cultures, verbalizing feelings and problems, and continuous empathic expression would be alien. RE does not require the couple to equalize their relationship, but allows opportunities for both parties to take turns to listen, express, discuss, and suggest solutions for challenges, adjustment, or change. Empathy, listening, and speaking are elements of RE that proved to be common to all ethnic groups. Empathy is a universal human process that guides interpersonal reactions (Decety & Lamm, 2006). Listening is a collective value, maintained by each culture’s rules of response. The rules may differ between cultures, depending on the weight placed on gender hierarchy, age, or status in society. Speaking is also directed by common rules of response or turn-taking, however, for most participants, speaking from one’s own point of view, and being specific and direct were novel ideas. By appealing to the universal processes, one can incorporate a fairly egalitarian process, while respecting gender hierarchies and gender roles. Furthermore, empathy can equalize power, if only in the moment or with a specific task. When combining that with couples’ goals for success in their new life, one can help refugees both work towards their goals and address perceived or actual threats.

Another challenge was in maintaining clients’ engagement in the skilled dialogue process; however this is not unique to the refugee group and depends on supervised practice with a skilled coach. The RE process with refugees is best facilitated with a trained and culturally attuned coach who can maintain relational hierarchies without challenging the culture. The aim is to minimize the hierarchical transference, which may be traditionally found with elders, that tends to give omniscient power to the coach (Mishne, 2002); the coach’s role is not to give advice, but to allow both parties opportunities for expression. The empathic process also allows associative identification of the therapist with the ego identification of the client. Associative identification is particularly important when the coach is from a different culture than that of the clients, as it allows opportunities to minimize cross-cultural conflicts (Shechter, 1992). There is a need for further study of RE coaching by both paraprofessionals and therapists in immigrant communities.

Flexibility and universality of application

This case study describes work with a recently arrived, young couple, at an early stage of acculturation and marriage. There are many future challenges that may affect their relationship. The RE skills and structured process of communication and problem solving is transferable to conflict with any issue or relationship, not just prescribed marital gender responsibilities (Accordino & Guerney, 2002, 2003; Scuka, 2005). While the training was offered to some couples separate from their partner, or to only one member of the family, findings cannot be generalized to those who learned and practice the skills separately.

This paper has illustrated the RE process through an example of conflict in gender roles. A quantitative outcome analysis of the program will be completed in the future. Other studies support the impression from these workshops that some first-generation newcomers, both refugee and immigrant populations, may need interventions to address the plethora of challenges related to both the old and the new culturally defined gender roles (Chang & Subramaniam, 2008; Nghe, Mahalik, & Lowe, 2003; Rehman & Holtzworth-Munroe, 2006). Service providers need to be aware of the role gender plays for each family, as there are individual differences based on traditional beliefs and rates of acculturation. Conflict in gender roles is often a key element in the presenting issue of marital (Espin, 1987; Nghe et al., 2003) and parenting problems (Chuang & Tamis-LeMonda, 2009; Williams, 2010). By applying the RE process, service providers can learn directly from their clients the role that gender plays within an individual or couple’s psyche. Quantitative studies of the short and long-term impact of RE on marital gender role adjustment are needed.

With limited availability of low-cost and evidence-based mental health services that meet cultural and linguistic requirements (Jamil, Ventimiglia, Makki, & Arnetz, 2010), the RE methodology can be incorporated into psychological interventions to address marital conflicts. Although the RE process is recommended for common martial problems, further study is needed of the application of the model as a secondary intervention with mental illness, substance abuse, and intimate partner violence. In addition to its use in psychiatric interventions, volunteers and paraprofessionals can be trained to apply, teach, and coach RE skills as part of a community mental health promotion strategy. Besides the required training and supervision in the model, there is no minimal educational or professional license required for coaches. Elders and leaders can incorporate the RE skills in their current cultural and religious approaches to helping. The RE model has been applied in marriage education workshops and in therapy in U.S. populations with Latino, Korean, Chinese, and Vietnamese communities and externally in 14 countries (relationshipenhancement.org). The adapted RE skills are available in several languages and can be used domestically and internationally with populations who speak Arabic, Burmese, Farsi, Karen, Nepali, Spanish, Somali, and Tigrinya. For more information and culturally adapted resources visit www.refugees.org/healthyfamilies and www.relationshipenhancement.org.