The grandfather-grandson relationship in Hong Kong.

This article presents a case study of a grandfather-grandson relationship observed in the course of family counseling conducted by a nurse in Hong Kong. It describes the skills needed to encourage both clients to speak honestly and openly. A grandfather-grandson relationship is commonly found in Chinese families when three generations live together and is a means of taking care of a grandson. Much literature encourages giving voice to male clients in counseling with sensitivity toward gender issues, but little is said about the importance of understanding the grandfather-grandson relationship. The case-study format was chosen to provide in-depth data on the grandfather-grandson relationship. Content analysis of videotapes of four family counseling sessions was carried out. The case illustrates the importance of avoiding stereotyping and suggests when grandfathers should step in or out of caring for a grandson. Although the methodology is limited by lack of generalizability, new insights into the family counseling process involving men were gained.

Keywords: grandfather-grandson relationship, grand parenting, counseling, case study, Hong Kong

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The grandfather-grandchild relationship is seldom mentioned in health care literature (Kolomer & McCallion, 2005), but discussion of relationships of this kind should be a focus of future research (Mills, 2001). Educating ourselves about the realities of women's lives (Harding, 1991) has been successful, however knowledge about men at both the conceptual level and in clinical practice has been inadequate to date. Health care professionals who work in medical, mental health, and rehabilitation settings with children and adolescents should adopt a gender-sensitive approach to help improve the recovery of grandsons raised by their grandfathers.

Health care practice does not place much emphasis on involving grandfathers in the process of treatment of their grandsons who might suffer from emotional or behavioral problems, yet approximately 2.4 million grandparents are raising their grandchildren in the United States (Watkins, 2006). There is no exact knowledge of the number of grandparents taking care of their grandchildren in the East. Denzin (cited in Berger & Quinney, 2005) reflected on his relationship with his father and grandfather after reading about Wallace Stegner's childhood. The untold stories of relationships between these men are revealed in lines such as this one, "I see two reflections: my father on the one side, my grandfather on the other. In this moment, as these two reflections come together, I see myself more clearly than ever before" (Denzin, 2005, p. 22). Denzin sees how his identity is affected by these two key male family members.

A contextual understanding of different kinds of grandparent/grandchild relationship is needed in order to reveal whether there are any similarities in such relationships across cultures (Ingstad, 2004). This study explores the grandfather-grandson relationship in the context of Hong Kong Chinese culture. It is concerned with the emotional ties that form between the two males and the counseling skills that can help them express their views toward each other. Specifically, it is a case study of a twelve-year-old boy who is being raised by his grandfather and who is considered by his grandparents and teachers to have emotional and behavioral problems.

Chan and Ma (2005) have stressed the need for gender sensitivity in the conceptualization and practice of counseling by nurses in the context of Chinese culture. To mitigate gender bias, we must realize that men, too, need to have a voice, and that this is an important factor in enhancing the quality of patient care. Male nurses may have a better understanding of male clients' stories, however, the majority of nurses in Hong Kong are females. It is therefore important to have a gender sensitive conceptual framework to guide nursing practice.

Three concepts are considered in the present study: fragmentation of relationships, tolerance of representations of otherness, and the revelation of secondary discourses in our society (Chambon, Irving, & Epstein, 1999, Davidson, 1977, DuBois & Miley, 1992, Dumm, 1996, Foucault, 1977, 1988, 1990). In the postmodern era, Foucault (1977, 1988, 1990) argued that there is no one single truth or one type of representation of a human relationship. For example, the definitions of effective or ineffective and joyful or painful when applied to relationships are socially constructed. Fragmentation of the grandfather-grandson relationship then means many presentations of this relationship can appear in one sociocultural context at one particular time in the same family. Tolerance requires us to admit that everyone has the basic human right to choose his own ways of interacting with another. It is also necessary when phenomena not matching our expectations and our own experiences emerge. In this study, uncovering secondary discourses refers to encouraging both grandfathers and grandsons to share the hidden stories and unspoken issues of their relationship.

Four main questions guided the data collection, analysis, and interpretation in this study: What are the experiences of the grandfather and grandson in their relationship? How is this relationship viewed in the context of their family as a whole? What are possible non-pathological interpretations of their relationship? How can understanding these relationships enrich health care providers' (especially nurses) clinical practice and guide future research?

Review of Research on Grandfather-Grandson Relationships

Not all relationships between grandparents and grandchildren are alike (Mueller, Wilhelm, Elder, & Glen 2002). Grandparents are typically regarded as big-hearted men and women who stand by their children and grandchildren (Wiggin, 2001). Most research of grandparenting has focused on grandmothers' experiences (Dench 2002), while grandfathers' experiences seem to be neglected (Kolomer & McCallion, 2005; Roberto, Allen, & Blieszner, 2001).

Three studies explored the experience of grandmothers raising grandchildren and yielded the following conclusions. First, in Asian countries like Taiwan, two crucial roles of grandmothers were identified: authority figure and alternate caregiver (Olsen, 1976). Second, grandmothers experience stress when they take on the role of main caregiver for their grandchildren, especially as the grandmothers grow older (Oburu, 2005). Neither of these two studies explored grandfathers' experiences. Third, there is a different degree of grandparental involvement between grandmothers and grandfathers. Maternal grandmothers are more devoted to caring for their grandchildren than other grandparents, and grandparents seem to give more time to a daughter's children than to a son's (Michalski & Shackelford, 2005). There is minimal research in Asian countries of gender differences between both grandparents and grandchildren.

Traditionally, a grandfather is viewed as the family head of three generations. He has a degree of decision-making power over his children and grandchildren. At the same time, he is respected by family members because he is usually the eldest male in the family, possesses rich life experience, and represents the dominant figure in the hierarchical family structure. Filipino-American grandparents, for example, regard their role as caregivers as a given and an obligation (Kataoka-Yahiro, Ceria, & Yoder 2004).

In all cultures, parental influences together with social norms and values affect grandchildren's perceptions of their emotional bonds with their grandparents. All of these issues are integral to the study of grandparent-grandchild relationships (Mills, Wakeman, & Fea, 2001).

If a grandfather is the sole male role model for his grandchildren he may take the role of surrogate father (Falk & Falk, 2002). This phenomenon seems to be common across different cultures. Blood ties and obligations to the family may explain why some grandparents take on the parenting role with little resistance. In some cultures, grandparents believe they should raise their grandchildren whenever and for whatever reason their children fail to do so (Falk & Falk). Yet, in some situations this transition from grandparenting to parenting may be questioned by grandparents themselves and by society (Kornhaber & Woodward, 1981; Wiggin, 2001).

Elderly people seem to use their past as a frame of reference for their relationships with the younger generation. Giarrusso, Silverstein, and Bengtson (2001) suggest that, among Mexican-Americans, grandsons have stronger affection for their grandfathers than their grandfathers have for them. Grandparenting can lead to greater life satisfaction for some grandparents (Bullock, 2004).

Sjaak (2004), who devoted almost ten years to anthropological fieldwork in a community in Ghana, found that older men seemed more neglected by their grandchildren than older women. Ross (2004) investigated the degree of stress in fifty African-American grandparents who were raising their grandchildren and found that 94% of grandparents said they experienced clinically significant levels of stress.

Some grandparents' support groups are reported to have been successful in such areas as building friendships, sharing grandparenting experience with other group members, and receiving relevant information for effective grandparenting (Waycie, 2006). However, little effort has been made to form grandparental support groups in Asian countries like Hong Kong. Overall, the grandfather-grandson relationship seems to have been largely ignored and devalued in the literature.

Method

Research Design

To ensure that the grandfather-grandson relationship could be fully explored, this study employs a qualitative approach. Qualitative research is inductive in nature and emphasizes the specific experience of the participants (Tesch, 1990; Thorne & Dorbyshire, 2005). It has been used in a majority of the research about family nursing and Asian families (Willgerodt & Killien, 2004). It can help us understand a meaning system that individuals use to interpret their actions as socially relevant (Ribbens & Edwards, 1998). It provides a detailed description of its subjects (Wilkinson & McNell, 1996) and allows breadth of inquiry (Mullen, 1995). These benefits ensure that a qualitative, case-study approach provides the most effective method for our research (Stake, 1995; Yin, 1989).

Background of the Clients

The relationship described involves twelve-year-old Tommy and his seventy-five-year-old grandfather from a Chinese-Hong Kong family. Tommy has lived with his grandparents since he was born, having been abandoned at the age of one after his parents divorced. Both parents later remarried. Tommy's grandfather, a physically active and alert seventy-five year old, was his primary care giver. His seventy-year-old grandmother had hypertension, and a history of cardiac problems requiring a week's hospitalization a few months before counseling started. To minimize Stress, the grandmother took less responsibility for Tommy after her hospitalization. The grandfather cared for Tommy and managed the family's affairs. He did not want his wife to attend counseling sessions, fearing that traveling to sessions and involving herself in Tommy's behavioral issues would tire her. The grandmother herself felt too sick to do so and was focused on her own health needs.

Tommy's two presenting problems were poor school performance and an ineffective relationship with his grandfather. Tommy was at secondary school. He was described by his grandparents and school teachers as having some psychological problems, including not sharing his feelings with family members, not performing well academically and having poor self-discipline. For example, he was absent from school at least one day a week because he could not wake up in the morning.

Ethical Considerations

The importance of protecting both clients from any potential psychological harm or distress through videotaping their counseling sessions was thoroughly considered. Appropriate written informed consent for videotaping the sessions and permission to use material obtained for staff development was obtained from both Tommy and his grandfather. They were informed that both their confidentiality and anonymity would be protected. Institutional ethical approval to use de-identified case material in a more intensive study was also obtained.

Analysis of Data

The content analysis of the data complied with the theory that requires data be analyzed systematically and intensively by constant comparison (Woolley, Butler, & Wampler, 2000). To capture the main content and to understand both the process and content in terms of all the sessions, the videotapes were reviewed three times at the end of each session and notes were made to facilitate the analysis. The first step was coding, to identify the ideas from the set of qualitative raw data and interpret them as concepts. The second step was thematization, to sort and categorize the concepts in relation to certain topics. The sessions were in Chinese. In what follows, only the most insightful segments have been translated into English.

Counseling Sessions

Four family counseling sessions were scheduled with Tommy and his grandfather. Before beginning the sessions my aims were to maintain my sense of curiosity about this family's story, to build a rapport with the family, and to ensure a safe and supportive atmosphere for both Tommy and his grandfather to tell their own stories.

The first session was used to build rapport with both clients and begin to understand their stories. The following three sessions were used to facilitate mutual understanding between the two clients by clarifying how I saw what they were experiencing as difficulties in their daily lives and encouraging them to voice their expectations of each other. At the end of the sessions, Tommy and his grandfather both understood they could contact me either by telephone or letter if they required further counseling or if they wished to share any news of changes to their relationship.

When I first met the pair I made eye contact with Tommy and asked him what he would like me to call him. He replied quietly, with his head down, that he wished me to call him "Tommy." I then greeted them both and welcomed them to their first counseling session. I spent the first fifteen minutes engaging Tommy by asking about his interests and daily life, without judging his behavior or giving any parenting suggestions to his grandfather. Tommy said that he liked cycling and watching cartoons. Tommy's grandfather showed great interest in this. His facial expression was tense and he looked closely at Tommy.

At the twenty-minute mark, the grandfather joined our conservation about how Tommy really liked cycling with his friends. He said, "Tommy's friends are naughty boys. I don't approve of them playing together."

Tommy showed disappointment at this comment, but did not argue. 1 did not confront the grandfather directly and respected his words. However, I sought clarification, and in a calm voice said: "Grandfather, you know that, since we are grown up, we might not be able to understand an adolescent's needs and feelings, even though we were young once. Do you want to hear from Tommy about his feelings?"

The grandfather said gently that he wished to hear Tommy's words as they seldom talked to each other at home. Then I moved my chair a little closer to Tommy and told him that we adults could not understand the adolescent's world as well as they could, as our adolescence was gone already. I tried to build rapport and encourage Tommy to speak for himself:

Counselor: How do you feel when you're cycling with your friends?

Tommy: I am happy.

Counselor: Why?

Tommy: We can talk about our difficulties in the transition from primary to secondary school life.

Counselor: What are these difficulties?

Tommy: Most of the homework is more difficult than primary school.

Counselor: How do you feel when you share this with your friends?

Tommy: Relief.

Counselor: Can you share your frustration at home?

Tommy: Never.

The grandfather then jumped into the conservation and said that he took Tommy to the park to cycle and, because he cared so much about him, he prescribed a cycling path of a particular distance for Tommy to ride. The grandfather even spent an hour watching Tommy ride. I did not comment that Tommy was already an adolescent and should have some freedom and autonomy to pursue relationships with his peers; instead, I expressed my sincere respect for the grandfather's nurturing attitude toward Tommy. Although such an authoritarian parenting style has a negative impact on children's psychosocial well-being (Tinsley, 1992), I could not condemn the grandfather since I could also see things from his perspective of a man who loves his grandson very much but said: "It is rare for a grandfather to go to so much effort for a grandson. I can see you love and care for Tommy unconditionally."

Looking at Tommy with tearful eyes, the grandfather said that he did everything he could for Tommy. This session made it clear that Tommy needed some personal space and the opportunity to spend time with his peers. He did not actively express his needs to his grandfather because he believed his grandfather would not listen, and because he was accustomed to receiving instructions from his grandfather. Though he was an adolescent, Tommy was still being treated like a child and the close surveillance by his grandfather showed that he did not allow Tommy a sense of autonomy and did not recognize that Tommy was growing up.

The first session also made it clear that the grandfather loved his grandson very much and tried to protect him by every means. Of course, it was not possible to understand the family dynamics thoroughly from just one meeting. I wondered whether if the grandfather had other people helping him to look after Tommy he would have been so involved in Tommy's life. On the other hand, Tommy was already twelve years old. If he really wished to object to his grandfather's views, he had not chosen to speak up and fight for the right to play with his friends. On the surface, Tommy was upset by the way his grandfather treated him as a child, but Tommy was also a loyal grandchild who did not wish to object to his grandfather. A cultural lens should be used here since, for example, Chinese families are more likely than Caucasian families to select endurance and non-verbalization as mechanisms for coping with distress (Willgerodt & Killien, 2004).

In the three remaining sessions, three therapeutic moves were made: to encourage Tommy and his grandfather to share their feelings with each other (e.g., love and concern); to clarify misunderstandings (e.g., that Tommy was not irresponsible about his study and personal care, the grandfather was not over-involved in Tommy's life, and the grandfather was willing to be more accepting of Tommy's peer relationships); and to empower both to master their new ways of interaction (e.g., they should communicate directly, respect each other's views, and voice clearly and constructively their expectations of each other). One significant post-counseling event was Tommy's teacher took the initiative to contact his grandfather regarding the positive change in Tommy's school performance. An interactive and partnership approach between family and school seemed to be helpful in Tommy's case (Martin & Hagan-Burke, 2002).

In the final session, Tommy assertively expressed his wishes to make his own friends and organize his daily routine by himself. The grandfather agreed that he should take care of himself and his wife and allow some room for Tommy to develop his personal skills. Both believed that they would take several months to adapt to this new pattern of interacting and would need to practice in their home context. This was a family-initiated termination (Wright & Leahey, 2004).

Relevant Issues

Three issues based on the case call for further research: stereotyping of grandfathers; indications for when a grandfather should step back from caring for his grandson; and cross-cultural and cross-gender considerations of the grandfather-grandson relationship.

The systems framework has proven to be effective in counseling practice for revealing a family's experiences (LeGrow & Rossen, 2005). In the brief case study presented above, the importance of mutual understanding and a non-authoritative, counselor-family relationship was shown. During the course of assessment and intervention, counseling with families should build rapport with every family member and maintain a non-judgmental view toward presenting problems. In particular, helping professionals should avoid stereotyping grandfathers and the level of their nurturing and compassion. Labeling grandparents as frail, docile, and traditional (Mills, 2001) is a process of medicalizing older people (Cheek, Shoebridge, Willis, & Zadoroznyj, 1996). For some men, the label "grandfather" makes them feel they have lost their machismo and their virility (Falk & Falk, 2002, p. 79). Edwards (1998) found that grandchildren who were raised by their grandparents might have poorer social skills and face psychological adjustment and developmental challenges, while others might have even more severe behavioral and academic problems. Blaming grandfathers for a grandson's behavior is not always constructive, however, as it can cause a grandfather to feel powerless, guilty, and judged as inadequate to the task of grandparenting.

Assisting a grandfather in his adjustment to participating in his grandson's care has been suggested. A grandfather's willingness to be involved and engaged in counseling sessions can result in his better understanding the grandchild's emotions and behaviors (Wilcoxon, 1987). When evaluating a grandchild's academic performance or other school behavior related issues, the influence of grandparents can be relevant (Edwards, 1998).

To lessen the strain on grandparents, support programs for those caring for addicted children have been launched (Trupin, 1993). Grandparents can provide encouragement within families and may, in some instances, arrange for help when their grandchildren have academic problems and wish for academic enhancement (Eckstein & Elliott-Applegate, 2000). It can be very important for grandparents to encourage a grandchild's academic development, but in many instances, this can be done best with outside support.

The respect between Tommy and his grandfather was reciprocal. In Chinese culture, the younger generations generally respect and care for older people (Winton, 2003). Tommy fulfills the role of a filial grandson by following his grandfather's suggestions and suppressing his own needs in order to avoid conflict with his grandfather. If the grandfather had continued to engage so closely in Tommy's daily life, however, he could have grown increasingly frustrated as Tommy gradually asserted his need for space and self-determination to grow up and explore his surroundings on his own.

Further Research

Most studies explore the grandfathers' experience and life and compare their relationships with grandchildren to grandmothers' relationships with grandchildren (Roberto et al., 2001). The cultural aspects of this study are of primary importance. Cross-cultural and cross-gender comparisons of the nature of grandfather-grandchild relationships should be promoted. Longitudinal studies especially may be more useful in revealing the health care needs of grandparents and their grandchildren (Grinstead, Leder, Jensen, & Bond, 2003). The effects of socio-economic status on grandfathers' experiences with child rearing should also be investigated (Kolomer & McCallion, 2005).

Strengths and Limitations of the Present Study

Both methodological and gender limitations should be noted. In further research, peer checking and inter-coder agreement should be included in the process of data analysis (Iosifides & Politidis, 2005). Although case study methodology is limited by lack of generalizability, new insights in regards to family counseling processes can be gained. Every clinical case is unique, and from each we can learn the unique stories of those involved. Examining actual cases can enhance the link between theory and practice and uncover personal assumptions and biases (Overton, 2005). The relationship pattern changes of this one case can be regarded as a single example only. Generalization to other, similar relationships may not be appropriate.

As a woman counselor I may have been limited in some ways in understanding experiences presented from a male perspective. However, whether male or female, all health care professions should treat all clients in a gender-sensitive way. I am also aware that my relationship with my own grandfather could affect the way I approach or interpret any clinical situation and that I need to be aware of this as part of my professional practice. All grandfather-grandson relationships have their own special circumstances and emotional ties that define them. My encounter with this pair encouraged me to reflect on the grandfather-grandson relationship, which has been neglected in health care literature and practice.

This study is the first to address the grandfather-grandson relationship in Hong Kong. It is also the first in both Eastern and Western countries to use a case study method. Although this study focuses particularly on the male grandparenting experience, further applications to health care research and practice are addressed by a central guiding idea of the study: the importance of giving a voice to commonly disregarded clients, respecting every client's choices and behaviors in his/her socio-cultural contexts, empowering people in their approach to health care, encouraging them to work as partners with health care professionals, and sensitivity to gender issues should be the guiding principles of our profession.

Conclusions

Reflecting on the process and results of this study, it is timely to call for nurses and other health professionals to recognize the increasing role of grandfathers in many modem families, not only in Hong Kong but throughout the world. This would include investigating the types and roles of grandfathers in various cultural contexts, the personal needs of grandfathers, and both effective and ineffective grandfather-grandson relationships in different family structures.

Nursing educators should encourage their students to hear every family member's story in order to provide humanistic and gender-sensitive care. Nurses should be also be aware of gender differences and avoid being judgmental about presenting problems and the process of counseling when handling grandfather-grandson related health issues.

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Zenobia Chan, Centre for Health Education and Health Promotion, School of Public Health, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong.

This paper was made possible to be published because of the constructive comments of the anonymous reviewers of this journal.

Correspondence concerning this article should be addressed to Zenobia Chan, Centre for Health Education and Health Promotion, School of Public Health, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong. Electronic mail: [e-mail]