American Journal of Hospice and Palliative

Medicine
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The Impact of Asian American Value Systems on Palliative Care: Illustrative Cases From the
Family-Focused Grief Therapy trial
Stephen Mondia, Shira Hichenberg, Erica Kerr, Megan Eisenberg and David W. Kissane
AM J HOSP PALLIAT CARE 2012 29: 443 originally published online 17 November 2011
DOI: 10.1177/1049909111426281
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The Impact of Asian American Value

Systems on Palliative Care: Illustrative
Cases From the Family-Focused Grief
Therapy trial

American Journal of Hospice

& Palliative Medicine
29(6) 443-448
The Author(s) 2012
Reprints and permission:
sagepub.com/journalsPermissions.nav
DOI: 10.1177/1049909111426281
http://ajhpm.sagepub.com

Stephen Mondia, BS1, Shira Hichenberg, BA2, Erica Kerr, MA2,

Megan Eisenberg, BA2, and David W. Kissane, MD2

Abstract
Background: Clinicians meet people from different ethnic backgrounds, yet need to respond in culturally sensitive ways.
This article focuses on Asian American families. Methods: Within a randomized controlled trial of family therapy
commenced during palliative care and continued into bereavement, 3 families of Asian American background were
examined qualitatively from a cultural perspective by listening to recordings of 26 therapy sessions and reviewing detailed
supervision notes compiled by each therapist. Results: A synopsis of each familys therapy narrative is presented.
Prominent themes include family closeness, respect for hierarchy within the family, gender-determined roles, intergenerational tensions, preoccupation with shame and limited emotional expressiveness. Conclusions: Family therapists working with
culturally diverse families need to pay thoughtful attention to ethnic issues as they strive to support them during palliative care
and bereavement.
Keywords
family therapy, palliative care, bereavement, Asian cultures, traditions

Introduction

The Model of Family-Focused

As immigration yields an increasingly diverse population in the Grief Therapy
United States, psychotherapeutic approaches including family
therapy during palliative care must be flexible to accommodate various cultures. At over 14 million people, Asian Americans constitute 5% of the US population, with Chinese,
Filipino, and Korean subgroups being dominant.1 Although
empirical research on family therapy and grief exists, there
is little focus on its efficacy with minorities, especially Asian
Americans.2,3 This is largely due to the portrayal of Asian
Americans as adaptive and well adjusted; their depiction as
a model minority is perpetuated by the general public and
mental health professionals.3 Nevertheless, Asians are still
vulnerable to mental health risks due to stressors associated
with immigration and acculturation.
Given this, there is value in exploring the experience of
Asian American families during palliative care using a cultural lens. We report on a case series of 3 Asian American
families that took part in a larger trial of family therapy during palliative care and bereavement. Our goal in this article is
to examine the challenges and opportunities that arise in family work and examine the cultural underpinnings that impact
on outcomes.

The overall model of family-focused grief therapy (FFGT)

seeks to improve in families shown by screening to function
less than optimally, 3 essential dimensions of family relational
life: cohesiveness, communication, and conflict resolution.
This is designed to help the family share its grief and cope
optimally as a result of improved teamwork and mutual support. In essence, by having the family transition from a stressed
to a better functioning group, they can progress through the
grief process in a more adaptive fashion.
Because disturbances in family functioning can lead to
maladaptive outcomes in bereavement, the larger FFGT study
sought to examine the dose of family therapy needed to prevent

SUNY Downstate College of Medicine, Brooklyn, NY, USA

Department of Psychiatry and Behavioral Sciences, Memorial Sloan-Kettering
Cancer Center, 1275 York Ave, New York, NY 10021, USA.
2

Corresponding Author:
David W. Kissane, Department of Psychiatry & Behavioral Sciences, Memorial
Sloan-Kettering Cancer Center, 1275 York Ave, New York, NY 10021, USA
Email: kissaned@mskcc.org

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American Journal of Hospice & Palliative Medicine 29(6)

444
morbid outcomes such as complicated grief disorder and
depression in the bereaved. Families were randomly allocated
into 3 study arms: 6 FFGT sessions, 10 FFGT sessions, or
standard care, where no therapy was administered. Because this
current project focused on the cultural aspects when family
therapy was given to Asian families, no standard care families
were examined.

Christian, dying from sarcoma;

Dermatologist & migrant
Caring towards children.
56

25

Methods
Eligible families had to be at risk of maladaptive outcomes
following the death of the cancer patient and so families were
screened with the Family Relationships Index (FRI).4 This 12item, self-report questionnaire is derived from the wellvalidated Family Environment Scale (FES) and measures 3
subscales: cohesiveness, expressiveness, and absence of conflict. Each subscale consists of 4 items and when added, a maximum score of 12 could be achieved. For the FFGT study, if 1
or more respondents had a total score of 9 or less, or less than 4
on the cohesiveness subscale, the family was thought to be able
to benefit from FFGT and hence eligible to participate.5,6
Within this Institutional Review Board (IRB)-approved,
randomized controlled trial, in which 170 families were
recruited, 3 families were identified as Asian American. The
therapists were social workers, psychologists, and psychiatrists
who had been trained to deliver FFGT and were regularly
supervised to ensure faithful adherence to the model. The
supervision sessions helped therapists to better understand each
familys dynamics, discuss any challenges, and clarify their
therapeutic goals. Audio-recordings of 26 therapy sessions
given to these 3 families and the therapists notes prepared for
supervision were studied in detail. Medical records were also
accessed to understand each clinical predicament but only relevant data are presented here. A literature review of Asian
American cultural beliefs surrounding end-of-life care
informed this overall examination.
As required by the IRB, complete de-identification was used
to protect each patient and familys privacy by changing
names, occupations, ages, some genders, residences, and other
sensitive information. The constellations of family relationships and their nationality have been retained to demonstrate
the effect of their ethnic values on the therapy.

Results
We report here a synopsis of therapy with 3 families whom we
have named the Mendozas, the Wangs, and the Zhaos to
illustrate Filipino, Korean Chinese, and Chinese American
families, respectively.

The Mendoza Family

Christian, a Filipino-born dermatologist, was diagnosed with a
rare sarcoma within his liver after experiencing an extended
period of severe abdominal pain (see Figure 1). He opted to
undergo chemotherapy, but as his disease progressed and it

Esteban, Dental student;

Intellectualizes issues;
FRI = 12

Myrna, nurse & now medical biller;

worried about children
FRI = 12
51

18
Alejandro, unemotional high school
student; close to father; FRI = 9

Figure 1. A Filipino family with stoical yet tender expressions of grief,

intermediate family functioning, where FRI Family Relationships
Index.

became apparent that he would die from this sarcoma, he and

his family decided to enroll in FFGT.
During therapy, Christian was extremely weak; he barely
spoke and needed to lie down during the sessions. He expressed
worry about how his family would cope. His wife, Myrna, also
had concerns for their 2 sons. She wanted both of them, particularly Alejandro, to be able to share their feelings and improve
their communication. However, after 3 initial sessions, Christian and his family opted to discontinue the meetings, feeling
that it was too much. Shortly after Christian died, Alejandro
had an angry emotional outburst causing his mother to reach
out to the therapist and ask for continued therapy.
The therapist was a Caucasian female psychiatrist trained in
using the FFGT model. In dealing with the Mendoza family,
she had a difficult time initially fostering emotional communication. Even when asked circular questions, wherein members
were asked to step into the shoes of the others and describe their
feelings, the sons would answer the questions logistically
instead of emotionally. For the Mendoza boys, intellectualization was their primary coping strategy used to deal with Christians illness and the grief associated with his death.
However, the children did comfort their mother in her times
of need out of obligation. Myrna declared that her childrens
embrace was important to her and she expressed distress when
she did not receive such comfort. Myrna yearned for her children to share in her grief, a goal that was gradually accomplished in the later sessions. When asked about hugging his
mother, Alejandro replied, I hug her every day when I leave
the house. At other times, I only hug her if she looks like she
needs it, [if she is] on the verge of crying. The therapist
affirmed the normality and benefit arising from these expressions of affection, gradually normalizing the grief and helping
the family to share as they comforted one another. The boys
learnt some words through which to share feelings as they met
together.
The family had a number of constructive outlets to reorient
their lives. Education and advancing ones career had always
been a family priority. The boys saw their school activities as
a way to live up to their fathers hopes and expectations. In a

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Mondia et al

445

Zhu, only speaks mandarin;

helps care for Mei
but creates conflict

Shao, no contact as
estranged from family

Unk

Died from lung cancer,

Chinese, Non-English speaking;

abusive to daughters

Involved in Huangs care

77

63

Jun, Korean stock broker;

optimistic about Meis cancer
FRI = 9

conflict
59
Yan, former

44

85

32

41
Mei , Chinese mother,
dying from colon cancer;
FRI = 8 BDI = 18

Liu, Chinese social worker,

helps care for Mei &
children; FRI = 7 BDI = 15

professor;
born in rural
China; involved
in Huangs

57

58
Huang, dying
from gastric ca
former school

54

Ping, School crossing

guard; Closest to
Huang

counselor, born
in Beijing; FRI = 8

care; FRI = 2
Shing

Elementary school children

Busy with activities
8
Pushed to excel

Emily

Jade

24

Medical student with busy

20
Vicky
College Student

schedule; FRI = 6

Figure 2. A blended Chinese Korean family with dominant views

about what is right and proper, where greater risk exists given lower
FRI scores and mild depression in dying mother and her brother. FRI
indicates Family Relationships Index; BDI, Beck Depression Inventory.

sense, they were commemorating their father through advancing their own education. For Myrna, both religion and extrafamilial support were also helpful to her mourning. Being a
Roman Catholic, she attended mass every day and frequently
went with her sons. She was also able to relate to and confide
in other women in her close circle of friends; they too had lost
loved ones to cancer. Myrna also garnered support from her 4
sisters, who took vacations and spent time with her after Christians death.
By the end of 10 sessions, the family appeared to have come
to terms with Christians death. The elder son, Esteban, felt more
comfortable talking about his father, and Myrna believed that her
relationship with her children had strengthened. She also stated
that therapy had made her childrens needs more apparent. As
the sessions terminated, Esteban voiced his desire to help Alejandro find his career path in college, while Myrna understood
the need to engage in activities with friends independently of her
sons. They all thanked the therapist for her support.

The Wang Family

When Mei, a 41-year-old Chinese mother of 2, had been consented to the study, very few months had passed since her initial diagnosis. She had begun chemotherapy and was
experiencing several side effects: hair loss, temperature sensitivity, weakness, and fatigue. Her quality of life was in decline
and she was less able to interact with her children. At the first
session, she and her husband began to describe her battle with
cancer (see Figure 2).
The therapist was a male, Caucasian social worker. He was
challenged often as the males in family were very outspoken.
Jun and Liu usually dictated the direction of discussion and primarily focused on finding a cure for Mei. When Mei wanted to
address her fears, they would quickly dismiss these as

Figure 3. A family from China brought up to please the other person

yet, at times, competitive with open hostility between the sisters,
reflected in their low FRI scores. FRI indicates Family Relationships Index.

irrational and instead concentrated on more optimistic

thinking. The therapist tried to adequately support the only
woman in therapy, noting in supervision that this was hard. He
had some difficulty understanding Meis reliance on religion,
which he described as mystical, and not fully comprehensible.
Throughout the sessions, Meis family provided substantial
support. Jun, her spouse, played a primary caretaking role,
encouraging her to be positive. Liu, her brother, also encouraged her to beat the cancer, but sustained regular visits to
Meis home and helped care for the children.
Meis mother, Zhu, was constant in running the household.
However, her demands to pursue Eastern medicine became
burdensome. Zhu blamed Mei for having developed the cancer,
arguing that cancer was not prominent in the family, so that
Mei must have done something wrong to bring it upon herself.
Indeed, everyone involved in Meis care saw her mother as
overbearing.
Mei struggled to please everyone in her support network,
ever the dutiful Chinese woman, but her main concern was for
her children. She worried about how she would be remembered, wanting her children to hold onto a lasting positive
image of her. Mei died after the fifth session. For a time in the
final session, there was disagreement among the men about
Zhus role in the lives of Juns children. Jun shifted the agenda
to concentrate on his childrens future, eventually winning
Lius commitment to help and support their needs.

The Zhao Family

Huang, a 57-year-old single school counselor, had metastatic
gastric cancer at diagnosis and was treated with palliative chemotherapy. She began to sob in the opening session because
she could not fulfill her brother Pings encouragement that she
exercise (see Figure 3). She was additionally sensitive to
extreme temperatures, felt weak, and had started to lose her hair.

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American Journal of Hospice & Palliative Medicine 29(6)

446
Nevertheless, she appeared optimistic about her future, yet was
irritable and emotionally explosive with her family, causing
some to withdraw and others to criticize her harshly. In light
of this, all of the family wanted to improve communication and
harmony.
The therapist was a female Caucasian psychologist who
sought to diffuse conflict that arose from miscommunication.
She encouraged the family to explore their ancestral and cultural
bases for these conflicts, hoping to strengthen familial bonds.
A high degree of conflict, coupled with low levels of cohesiveness and communication, pervaded the sessions. These
arguments revolved around the familys tendency to speak but
not listen to each other; this pattern was most evident in
Huangs relationship with her elder sister, Yan, for whom she
carried long-lasting grudges. Huangs nieces, Emily and Vicky,
felt detached from these battles between their aunts, but curious
to understand what caused them.
The sisters resented their fathers negative influence in fostering much distrust of men, on which they blamed never marrying. The father was abusive, both physically and emotionally,
creating fear that a husband could be like him. Moreover, the
sisters could not confront failure well. Huang believed that her
main priority was to be perfect for everyone, a duty that had
been drummed into her as a child. The connection between the
familys unhealthy communication and the fathers influence
was a key focus for the therapist. She allowed Huang and her
siblings to explore this and openly share the experiences they
had with their father, fostering consideration that they could
begin to trust more and relate better.

Discussion
Cultural Themes
These 3 Asian American families displayed culturally influenced coping strategies that provided opportunities for
effective therapy. Alternatively, culture may serve as an impediment that blocks understanding. Familial hierarchy, balance
in gender-based power, intergenerational relationships, preoccupation with shame, and limiting emotional expression
emerged as themes from their ethnic backgrounds. In order to
facilitate communication, enhance cohesion, and decrease conflict, the therapist must be cognizant of these cultural values
and know how to properly manage any resultant tensions.
A hierarchy of power was apparent within each family structure; in general, the line of authority extends from the father to
the mother to the firstborn son to the last child.7 This ladder of
power highlights the importance of filial piety, which is especially revered in Chinese American families.8
In the Mendoza family, the constructs of familial hierarchy and filial piety created conflict. Once Christian had
died, Myrna became the authority over her children. During
therapy, she asked for physical comfort from her children;
whether their actions were authentic or done out of obligation created concern for Myrna. In a Filipino family,
younger members are expected to obey their elders,9 giving

rise to a perception of obligatory sympathy that Myrna

received from her children.
Similarly, a strong sense of duty created tension in the Wang
family. Mei as a daughter to Zhu was expected to follow her
instructions about Eastern medicine; on the other hand, as a
wife to Jun, she was expected to fulfill his wishes. There were
many demands for Meis loyalty, which collectively manifested as an obstacle to coping.
For the Zhao family, the father had exercised his superior
power to create regret and resentment. He was abusive,
demanding, and harsh toward his daughters, which stemmed
from his cultural preference to favor his sons. His treatment
of his children set them up to unhealthily compete with each
other; they strived to gain his approval at the cost of personal
fulfillment. Wang and Heppner10 showed that any discrepancy
between perceived parental expectations and ones performance generated distress, including depression and anxiety.
Huang and Yans inability to please their father and their tendency to compete may have given rise to the dysfunctional
communication evident during therapy.
The hierarchical family structure of the Wang family also
exemplified the male dominance that can be culturally determined. As a result, Meis desire to leave a legacy for her children seemed sidelined. It was striking how Jun and Liu took
control of the pace and subject matter, focusing primarily on
their goals and what they thought was good for Mei. Such patriarchal behavior is especially common in the Korean culture.
The idea of women being subordinate to their husbands is
found among older Asian couples.11 Unfortunately, abusive
partnerships and domestic violence may result from this.3,12
Such male dominance hindered communication about Meis
illness and subsequent sharing of grief.
Another cultural theme that decreased cohesion was difference in lifestyle and beliefs between immigrant parents and
their children as they acculturate to life in the United States.13
Immigrants tend to ally with the traditions of their home country, while subsequent generations take on the customs of the
host country. When these clash, conflict readily appears.
Thus, Filipinos expect a person to be perceptive of anothers
needs, as seen with Myrna. Yet an American-born child such
as Alejandro lacked an ability to do this, leading to intergenerational conflict.11 Alejandros style of providing comfort
to his mother out of superficial obligation rather than responsiveness to her distress created a disconnection between these
family members.
Another illustration of intergenerational misunderstanding
was seen between Mei and her mother, Zhu, who expected Mei
to adhere to Eastern practices of taking daily herbs and mushrooms. This practice can be traced back to Zhus roots in Taoism, where the balance of Yin and Yang must be achieved
through natural means.14 In addition, Zhus attribution of
blame that Mei caused her illness arose from the Buddhist
belief that ones actions will lead to appropriate consequences.
Cancer was brought on by something she had done wrong in
her past.15 Knowledge of cultural traditions is crucial to address
such intergenerational issues.

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Mondia et al

447

Similar intergenerational strain was apparent in the Zhao

family, where Emily and Vicky were second-generation descendants of immigrant grandparents. Their alliance with Western beliefs and lifestyles led to a gap in understanding their
parents experience.
The concept of shame and its relationship with the lack of
overt emotional expression is another noteworthy Asian American cultural feature. The Mendozas may have pulled back
from therapy because of the risk of losing face in front of strangers with too much emotionality. In the Filipino culture, the
concept of hiya, or shame, signifies embarrassment and fear
of perceived inferiority.9 This can block seeking help from outside the family.16 Hiya can impede sharing feelings. A related
concept is machismo, wherein Filipino men are expected to be
hyper masculine and prideful.17 In therapy, both sons voiced
their opinion that being silent about feelings was important to
maintain a masculine composure, a stance perpetuated by both
parents. The mother even exclaimed at one point, Theyre not
girls! They dont show emotions! Therapy that is generally
supportiveexpressive in style needs to accommodate and
respect this machismo concept with its proscription against crying. Esteban was always trying to fight his tears during therapy. Shame contributing to emotional suppression was also
prevalent in the Wang and Zhao families, lest it be seen as
weakness and a loss of face.

Clinical Implications
The FFGT therapist poses questions and remains curious about
the many ways that culture can affect the processing of grief.
Importantly, the therapist should not try to personally solve the
problem, but rather empower the family to work together to
draw culturally sensitive conclusions about their coping and
mutual support. The therapist remains neutral, yet insightful
and reflexive enough to help unpack any points of cultural
struggle for the family. By providing behavior-oriented goals,
addressing members in an order that respects cultural hierarchy, understanding any intergenerational tensions, creating a
strong alliance with all family members to foster culturally
sensitive expression of feelings, the therapist will optimally
support the family.
Kim has recommended that family therapy be problemfocused, goal-oriented, and symptom-relieving when
working with Asian American families, rather than focused
on expression of emotion.7 Within the FFGT model, the therapist seeks to empower the family to set their own goals, which
aims to be culturally sensitive in the process of doing this. For
the Mendoza family, focusing on behavior let the family share
their grief. The therapist initially used circular questioning to
promote communication but was often met with answers that
were purely short, factual, and avoidant. For example, when
asked, What do you think would happen if Esteban shared his
feelings more? Myrna would answer, Well, he could express
his feelings if he feels depressed, but there are many things to
do aside from getting into depression. Her action-oriented
suggestions were culturally sensitive and did include the use

of affection and provision of comfort. Eventually, such behaviors improved the closeness of their family.
Familial hierarchy and male-dominated family structure
were other cultural impediments that could block the progress
of FFGT. Therapists who do not understand these cultural
themes may struggle to make sense of the family dynamics and
could fall into the trap of aligning with the men, to the neglect
of the women, or vice versa. Asking the family-as-a-whole who
should respond first to any question will allow the family itself
to determine the order of respondents. If it seems that the men
are dominating a session, the therapist can empower the women
by introducing questions about their culturally accepted roles
and strengths. Chung et al12 argue that Asian women draw their
power from their household roles; they are responsible for managing finances, caring for children, and performing household
duties. By establishing their valuable contributions to the family, communication can be fostered alongside respect.
Addressing intergenerational conflict can be challenging, as
seen in the Wang family. Lee, Su, and Yoshida18 propose using
social support seeking and problem solving to deal with intergenerational differences. In Meis case, where acceptance and
avoidance were her usual coping methods to deal with her
mother, the therapist might have asked her to reflect on the value
of her relationship with her mother, leading then to ways she
could extend her support network or engage in problem solving.
Building a therapeutic alliance with members of a very dysfunctional and fractured family deserves consideration, as
some are help rejecting. Pandya and Herlihy19 suggest that
safety is a key element here. A safe environment for the Zhaos
was achieved by minimizing instances where they could lose
face. The processes of losing face and feeling embarrassed are
related to the prominent sense of shame found throughout
Asian cultures. Normalizing these reactions is helpful and can
further strengthen the therapeutic bond. These techniques
helped the Zhao sisters to better understand their fathers contribution to their competitive style, paving the way for
improved mutual support.
A final strategy is the use of an intermediary to link with
uncommunicative individuals. This intermediary can transmit
information across boundaries and create the opportunity to
reconcile estranged or conflicted relatives. For the Zhaos, the
intermediary was Ping. When he was present, his sisters were able
to communicate about their differences more constructively.

Limitations
There were only 3 Asian American families out of the 170
families enrolled in the larger trial. Because of this limited sample size, it is difficult to generalize the findings. More research
would be needed to explore many of the other existing Asian
subcultures.

Conclusion
Detailed examination of a cultural group such as Asian Americans deepens our understanding of their traditions and issues

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American Journal of Hospice & Palliative Medicine 29(6)

448
that potentially impact on the outcomes of family therapy. This,
in turn, assists us to ensure that such therapy is culturally
sensitive and responsive to each familys needs.
Acknowledgment
We thank the many clinicians, therapists, research collaborators, and
colleagues contributing to this work.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to
the research, authorship, and/or publication of this article.

Funding
This study was supported by a grant from the National Institutes of
Health [R01 CA 115329] to DWK, Principal Investigator.

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