Addressing Cultural Issues in Grief Counseling With Immigrants: The Case of a Bereaved Filipino Family Following Homicide

This article discusses cultural considerations and approaches to working with bereaved immigrants who cope with traumatic loss. A clinical case is used to elaborate on issues related to cultural identity, level of acculturation as well as religious beliefs and rituals among Filipinos living in Greece. Considerations for clinicians, who provide services to culturally diverse families that experience traumatic deaths, are discussed.

The European Journal of Counselling Psychology ejcop.psychopen.eu| 2195-7614 Large influxes of asylum seeking refugees and irregular migrants, who view Greece as the main gateway to Europe, created a humanitarian crisis in 2015.More than one million crossed the Greek borders and headed for central and northern Europe.However, after the closing of the Balkan route in February 2016, and the European Union-Turkey refugee agreement in March 2016, arrivals by sea have significantly decreased but still an approximate number of 40,000 asylum seekers (and/or irregular migrants) are stranded in Greece waiting, either to relocate or indeed integrate in the country (Triandafyllidou & Mantanika, 2016).
The increasing phenomenon of cultural diversity requires that mental health practitioners acquire knowledge and understanding on how cultural issues affect responses and meanings attributed to loss, adversity, and life experiences.These may significantly differ from the clinician's.Cultural, religious and spiritual beliefs affect bereavement, and, as a result, clinical assessment of a person's grief should always consider individual, family, social, and religious factors, including the client's level of acculturation.Such in depth exploration shapes the professional's approach and choice of interventions as to address the person's or family's needs (Brutus, 2009).
The available literature on the support of traumatically bereaved Filipino families, comprising first-and secondgeneration immigrants, is sparse.Only a few articles and unpublished dissertations explore how spirituality influence the way individuals construct meaning(s) of life events and cope with life challenges, including the loss of a loved one (Macabulos, 2015;Shimabukuro, Daniels, & D'Andrea, 1999).
The present paper seeks to contribute to the bereavement literature in three distinct ways: (a) by presenting a short overview of the key issues that clinicians must bear in mind when working with bereaved immigrant adults, adolescents and young children, (b) by describing a clinical case of a Filipino family that sought grief counseling after the homicide of a senior family member (due to confidentiality, all names have been changed), and (c) by sharing some of the challenges in providing support to this population.

Cultural Identity
Culture, according to sociologists and anthropologists, refers to the "social heritage of a community", that is the sum total of the possessions, ways of thinking and behavior, which distinguishes one group of people from another and is passed down from generation to generation (Parkes, Laungani, & Young, 2015).Identity refers to one's perception of self or how one views self as unique from others.Racial, cultural, and ethnic identities form part of one's identity, and that identity changes with development both at a personal and social level, including migration and acculturation (Bhugra, 2004a(Bhugra, , 2004b)).A person's cultural identity is affected by one's religion (spiritual beliefs and rituals), rites of passage, language, history, dietary habits and leisure activities (e.g.music).These components ensure the person's belonging to his or her culture while living in a different cultural context, and may or may not change during the acculturation process (Bhugra, 2004a).
Acculturation is a multidimensional reciprocal and dynamic process resulting from the interaction of a migrant's culture of origin with the culture of a new homeland, and refers to the changes in cultural values, customs, beliefs, attitudes, language and behaviors that result from constant intercultural contact (Berry, 1997).It has been proposed that two independent dynamics underlie acculturation: one is focused on cultural maintenance of the heritage culture, and the second involves the interaction with the culture of the host society (Berry, Phinney, Giannopoulou, Bitsakou, Ralli et al. 201 Sam, & Vedder, 2006).According to this model, minority group members have either strong or weak identifications with their own or mainstream cultures, thus, giving rise to at least four types or modes of adaptation: assimilation, integration, separation and marginalization.The social and cultural qualities of one's identity are typically more resistant to change and are usually last to adjust during acculturation (Bhugra et al., 1999).The level of acculturation reflects the degree to which an individual adheres to the cultural norms of the dominant society, whereas, the level of enculturation refers to the degree to which people retain the norms of their culture of origin (Kim & Omizo, 2006).

Cultural Issues in Bereavement
Each culture has its own traditions, rituals and ways of expressing grief and mourning.It is important for clinicians to understand the religious and spiritual beliefs about death, as well as the cultural background of their clients, in order to foster empathic understanding.Knowledge of beliefs about death, as well as of burial customs, funeral and mourning practices aiming at honouring, respecting, and remembering the deceased, are all aspects of paramount importance that guide assessment and choice of therapeutic interventions (Neimeyer, Klass, & Dennis, 2014).It must be born in mind that all individuals belonging to the same culture or religious group are not "similar" and do not necessarily share identical values, life styles, or socio-economic and educational backgrounds, nor abide to the same beliefs, rituals, and practices.Level of acculturation should be considered, as this may be an added stressor throughout bereavement.Research findings suggest that higher levels of reported "acculturative" stress (i.e. the distress effects of adapting to a new culture) are associated with decreased quality of life, including physical and mental health well-being (Belizaire & Fuertes, 2011).

Beliefs About Death From a Filipino Cultural Perspective
Filipino immigrants' funeral and mourning practices have been influenced by the combination of Christian and animistic beliefs associated to death and afterlife.Memorial rituals vary according to one's family, economic status, and level of acculturation to the host country (Shimabukuro et al., 1999).Roman Catholic Filipino immigrants engage in practices similar to those performed by the Roman Catholic Greeks, who are a religious but not an ethnic minority, given that the prevailing religion is the Greek Orthodox Church.Wakes and a 24-hour vigil are key rituals in the mourning process.During the wake, the cleaned and embalmed corpse is placed in a coffin, displayed at the house of deceased or at a funeral home (Clark, 1998).A wake is conducted every evening, so as to celebrate and remember the life of the deceased.Family members take turns to ensure that someone is always holding vigil for the deceased.Visitors who seek to pay their respect may come at any time of the day or night until the wake is concluded.A Filipino wake is not designed to be short or quick, with most lasting 5 to 7 days.Regardless of the level of acculturation, a death in the family will often elicit the involvement of all extended family members and the community.Respect for the deceased is displayed through obedience to rituals.White is the color to wear during the funeral, and black throughout the mourning process.
Many Filipinos use rituals that are based on animistic beliefs, which suggest the existence of an ongoing interaction of spirits with the living.Thus, talking to the deceased person's spirit, experiencing visits from other spirits, angels or ghosts, performing cleansing rituals, and avoiding to sweep the deceased person's home until the burial is concluded, in order to prevent the spirit being swept away, are common practices (Shimabukuro et al., 1999).When someone is killed as a result of murder or homicide, relatives put live chicks on his or her cas-Cultural Issues in Grief Counseling With Immigrants 202 ket made of glass.It is believed that the sound of the chicks pecking on glass will hound the killer's conscience, and bring the murderer to justice.
After the funeral, family members and friends gather for nine nights of prayer, which correspond to the nine days before the soul of the departed enters the spirit world.The last night of prayer ends with a huge feast that represents a celebration of the life of the deceased.On the 40th day, which corresponds to the Christ's resurrection and ascension, a special prayer service or mass is held for the soul, which ends its earthly wandering and ascends to the afterlife.The bereavement period extends for a period of one year when another service is held on the first death anniversary (Clark, 1998).The existence of spirits is strongly embedded in the Filipino culture; it is not uncommon to talk about deceased relatives "visiting" family members in their dreams or during waking hours, thus, suggesting the maintenance of a continuing bond among the living and the deceased (Shimabukuro et al., 1999).Children are often perceived as mediums who receive messages from the dead (Atuel, Williams, & Camar, 1988).

Grief After Homicide
Homicide is among the most devastating forms of violent death.Those left behind are often referred to as 'homicide survivors' or co-victims of homicide.Their experience is characterised by both grief and trauma (Spungen, 1998).The effects of homicide on the bereaved usually are severe and long-lasting (Stevenson, 2008).The grieving process is affected by the quality of the relationship with the deceased, the age and loss history of the survivors, the degree of exposure and conditions in which the murder occurred, the family's social support network, and its cultural and social characteristics.If the death was caused by an unknown person, countless hours may be spent trying to understand why the stranger chose to kill one's loved one.While several scenarios are considered, including the belief that one's death was due to a curse, guilt, anger, distress, and fearful thoughts are common among the bereaved (Cox, 2008).Their grief does not follow a predictable course, nor unfolds in stages, but is more complicated and may be prolonged as a result of extended legal procedures and social stigma (Stevenson, 2008).
Survivors are unable to understand or believe what happened to their loved one; they feel helpless and powerless, guilty over not having protected the victim, are haunted by images, nightmares, and flashbacks of the murder, even if they did not actually witness the crime.Furthermore, they may experience severe rage toward the perpetrator(s), become afraid of strangers, worry it may happen again, and experience a profound loss of safety.After such an "unfair" and unnatural event, it is not uncommon to question their religious faith in God, who let something so tragic happen to their loved one (Cox, 2008).
The violent death of a family member is a confusing and frightening experience particularly for children, and especially for pre-schoolers, who lack the cognitive ability, emotional maturity, and coping strategies to manage their grief.Children whose parents have been murdered exhibit a wide range of behavioural and developmental problems.They may suffer intense stress develop psychosomatic symptoms, phobias, and depression, and/or manifest dysfunctional thinking over the event, ambivalent feelings, guilt and blame themselves for not having had done something to prevent the killing (Stevenson, 2008).Their grief is atypical and does not reflect the dual process of coping with bereavement, as described by Stroebe and Schut (1999).Their model posits that two processes occur side by side in the everyday life of a bereaved person: a loss-oriented process, which entails active grieving, rumination over death issues, thinking of the deceased, imagining how he or she would respond Giannopoulou,Bitsakou,Ralli et al. 203 to different situations, and a restoration-oriented process, which entails attending to life changes and adjusting to a world in which the deceased no longer exists.Healthy grieving involves an oscillation between loss-and restoration-orientations, which allows for an effective adjustment to loss.According to Rynearson, Correa, Favell, Saindon, and Prigerson (2006), when the death is violent, the oscillation process is compromised.The bereaved experiences highly distressing imagery involving reenactment of a loved one's death and a deconstruction of one's life story.Therefore, the primary goal of intervention is helping the bereaved to restore a sense of safety and facilitate family resilience (Salloum & Rynearson, 2006).

A Case Study Illustration of the Grief Process of a Filipino
Family Following Homicide

Background Information About the Event
Nannay, (Filipino title for great grandmother), member of a Filipino family residing in Greece for 20 years, was murdered by two men in her house in the presence of her youngest, 4-year-old, great grandson, Ed.Roger, aged 14, was the first to reach the crime scene.He found his great grandmother lying dead on the kitchen floor and his younger brother, tied up with his mouth being sealed with a tape.He immediately released Ed, who was crying and in great distress.Sonia, his 13-year-old sister, reached the house when Roger was calling the neighbors for help, but was prevented from entering the kitchen and did not see her murdered Nannay.The police investigation concluded that the cause of the homicide was burglary.One of the two men was arrested.The family moved immediately after the homicide into another apartment.

Assessment
One month after the traumatic event, 60-year-old "Mammy" (Filipino title for the grandmother) referred the family to "Merimna", a Greek non-profit organization which provides bereavement counseling services in Greece (Papadatou, 2010).She was concerned about her grandchildren and especially about Ed, who witnessed the crime.Consent to support the children was obtained from the mother who had no request for counseling and did not attend the sessions due to her long working hours.The relationship between children and their mother was not as close since both the great grandmother and the grandmother assumed their upbringing and daily care.Mammy was the children's main caregiver and, therefore, the main contact person.None of the male adult members of the family requested psychological support, nor attended any of the sessions, despite the fact that they were invited to participate.This did not allow the clinicians to address grief manifestations of adult male family members and explore how these might have impacted on family dynamics following the violent death.
Mammy's level of acculturation to the Greek society was low as she mostly socialized and identified with her own cultural group struggling to maintain traditions.She did not speak Greek but her English was good enough to conduct counseling sessions.During the initial assessment interview, she was informed that it is common practice at "Merimna", to first have a separate session with each family member so as to understand their subjective loss experience and identify their needs, and then propose an intervention, which may include individual and/or family sessions, participation in support groups or referral for psychotherapy.

Cultural Issues in Grief Counseling With Immigrants 204
During that first session, it became apparent that Mammy suffered from posttraumatic stress symptoms and intense bodily pains.She was overwhelmed by grief over her mother's violent death and by the new matriarchal role she had assumed, which involved looking after all family members (i.e.food preparation, chores, psychological support, etc).Three key aspects were predominant in her grieving process: (a) spiritual beliefs, involving the performing of rituals to "call" and communicate with Nannay's spirit over 40 days post-death, (b) inability to perform, in Greece, some culturally sanctioned purification and soul releasing rituals (e.g.placing leeches on the corpse in the coffin), and (c) the ascribed new family role as "the senior female", which involved, among other things, the support of her grandchildren, and in particular of 4-year-old Ed, who witnessed the homicide and was assaulted.
Ed spoke only Filipino P and, therefore, his grandmother, acted as an interpreter during the initial interview session.According to Mammy, he had become fearful and very clingy after the homicide, had great difficulty sleeping alone, woke up crying during the night, and displayed severe temper tantrums during which he screamed and/or hit particularly his grandmother.She held the belief that Ed often acted as a medium who was able to receive messages from Nannay's spirit.Ed was experiencing separation anxiety and requested Mammy's presence throughout the session.At her attempt to leave the room, he became angered, irritable and hypervigilant.
She was, therefore, asked to stay but whenever she attempted to talk on his behalf, Ed screamed and hit Mammy, who felt helpless to calm him down.
Roger, a 14-year-old second-generation immigrant, was assimilated to the Greek culture, doing reasonably well with school work and getting along with Greek peers.He reported that he felt mostly "Greek" and questioned some of the Filipino cultural beliefs and values.Clinical assessment indicated that he was suffering post-traumatic stress symptoms.He was distressed by recurrent and intrusive thoughts, images and smells related to the traumatic event, and avoided trauma-related stimuli (e.g.Ed's crying) and reminders (e.g.being in the vicinity of the house where the crime took place).The narrative of his experience was fragmented.He reported irritability, mood swings, a profound sense of threat, the manifestation of startle response, and a profound discomfort with the family's communication with spirits during the 40 days after Nannay's death.The belief in the continued presence of his great grandmother's spirit was evoking intense fear and psychosomatic reactions.For example, he was worried that he may hit, with the ball, his Nannay's spirit who was around him, while playing basketball.As a result, he either avoided playing basketball or displayed psychosomatic reactions, such as headaches and vomiting, whenever he participated in a game.
Sonia, a 13-year-old second-generation immigrant adolescent, was assimilated to the Greek culture, coped effectively with her transition to secondary school, and was achieving academically well.During the initial clinical assessment, it became apparent that she was experiencing high levels of anxiety in relation to the culturally embedded belief of Nannay's spirit and fear of ghosts.She had nightmares, almost every night, displayed mood swings, concentration problems and was short tempered.In an attempt to control her fears, she started watching terror movies.Even though she was expected to assume a more active role and contribute to food preparation, household chores, and looking after her younger brother, she persistently refused to take up these female responsibilities, which led to ongoing tension and conflict with her grandmother.

Course of Intervention
The intervention was based on Rynearson, Correa, Favell, Saindon, and Prigerson (2006) approach, which focuses on building resilience and concurrently managing the traumatic aspects of loss before coping with bereavement.After the initial assessment with each family member, it was decided to proceed with individual rather than family sessions, since the sharing of narratives might have been re-traumatizing for some family members.In order to address stressors associated with trauma and grief issues in the family, the clinicians involved in the case received group supervision twice a month.
Given Ed's severe traumatization he was referred for trauma-focused play therapy with a recommendation to involve a professional interpreter.Bearing in mind his chronological age and developmental needs, the intervention with his grandmother, among other goals, included helping her to understand and manage his emotional and behavioral changes.
Over the course of 12 sessions with Mammy, four goals were identified and achieved: (a) process trauma responses so as to control intrusive memories, (b) facilitate the grieving process and meaning attribution to her mother's death, (c) empowerment in assuming new responsibilities, and (d) facilitating support of her grandchildren.With regard to the latter, she was helped to understand the differences in grief reactions between adults and children, and to recognize the ways in which spiritual beliefs embedded in the Filipino culture had affected her grandchildren's grief reactions.She came to realize that Roger's refusal to participate at family prayer services was not a dishonor to the deceased but rather an avoidance coping strategy, since Ed's crying acted as a reminder of the traumatic event.She was also helped to understand how her own spiritual beliefs, which helped her cope with loss, were causing her grandchildren intense fears.peer pressure, cultural and social identity formation).

Discussion
The described grief process of a Filipino family living in Greece illustrates a variety of cross-cultural aspects that pose challenges to clinicians.First, it highlights the unique albeit universal aspects of coping with the sudden and unnatural death of a family member through homicide (Cox, 2008), while concurrently experiencing a grieving process that is affected by personal, family, social, religious and cultural factors (Neimeyer, Klass, & Dennis, 2014).
Second, it sheds light on how spiritual beliefs shape grief reactions in family members with different levels of acculturation.Of particular interest in the presented case, is the nature of ongoing spiritual connection with the deceased, which was experienced differently by various family members, depending on their level of acculturation in the host country.Both adolescents, who were second generation immigrants, were encouraged by the family to believe in the existence and wandering of the great grandmother's spirit, which evoked strong fearful reactions that negatively affected their daily functioning.In particular, the boy's persistent avoidance of playing basketball with his mates to prevent harming his great grandmother's spirit with the ball, and the girl's fear of "visiting" spirits and ghosts after the death needed to be explained and dealt within a culturally sensitive context, rather than labeled as "mental health problems".The grandmother's belief that her mother's spirit was communicating with and through the youngest grandchild, because of his presence at the crime scene, impinged on her "parenting" ability to manage effectively his severe emotional outbursts.Her perception of him as a medium, which ensured the continuing bond between the family and the deceased, compounded by her own overwhelming grief, interfered with her ability to support the child by recognizing and responding to his developmental needs.
Third, this case brings up the difficulties that immigrants face in performing culturally sanctioned rituals as a result of homicide while living in the host country.The wake and the 24-hour vigil did not take place according to traditional customs, given the transfer of the corpse to the morgue for autopsy examination.Moreover, the inability to perform specific purification and soul liberation rituals increased the grandmother's belief that her mother's spirit was earthly wondering for longer than 40 days.Therefore, "seeing" or "feeling" the presence of the spirit for a prolonged time needed to be understood within the framework of coping efforts with great grandmother's unnatural and violent death.
Fourth, taking time to acquire knowledge about the spiritual beliefs and traditions of bereaved people with a different cultural background enables clinicians to understand grief and trauma responses from a culturally sensitive perspective (Walter, 2010).Questions that can facilitate deeper exploration of personal, cultural and reli-  Giannopoulou,Bitsakou,Ralli et al. 207 tices that are meaningful to families enables the bereaved to feel accepted and safe in the counseling process.
Understanding the added stress derived from the different levels of acculturation, can help clinicians plan and implement a multilevel intervention that best addresses the individualized needs of family members while promoting and supporting positive changes.Finally, recognizing differences between own beliefs regarding death and grieving and those of immigrants can increase tolerance and empathic understanding in the context of multicultural counseling.
In conclusion, to communicate effectively and support bereaved immigrants, clinicians must acknowledge their stereotypic attitudes and be able to gather information about how children and adults of a different culture and religious background perceive life, death and cope with loss of a loved one.Moreover, they must acknowledge and contain their personal anxiety and tolerate uncertainty in the face of cultural variability.Only then, they can be mindful of others and provide a safe space for the bereaved.
figure.Thus, she was helped to interpret Ed's behavior in a new light, and cope more effectively with what she perceived as "misbehavior", evoking high levels of anxiety and embarrassment.Finally, given that religion was identified as a source of strength in her daily life, she was encouraged to maintain her involvement with the Roman Catholic Church in the Filipino community.Over the course of 12 sessions with Roger, two goals were identified and achieved: (a) work through traumatic grief responses so as to control intrusive memories, and (b) support through grief by acknowledging the effects of the Filipino mourning practices.Our intervention was initially focused on the normalization of his traumatic reactions that resulted from his direct exposure to the crime scene.He was helped to understand how the systematic avoidance of intrusive reminders was preventing the emotional and cognitive processing of his traumatic experience.The Eye Movement Desensitization and Reprocessing (EMDR) technique was initially used for alleviating his distress over traumatic memories, before shifting focus on grief work.Roger, eventually, became aware of how cultural and spiritual beliefs embedded in the Filipino culture, were linked to some of his reactions, and was encouraged to progressively attribute a non-threatening meaning to the spirit of his great grandmother.Over the course of six sessions with Sonia, two goals were identified and achieved: (a) reduce the frequency and intensity of her spirit-related fears, and (b) supporting engagement in life-affirming activities without feeling gious beliefs, rituals, and norms associated with bereavement include: What relationship is maintained with the deceased?Ηow is the dead handled?How is the memory of the deceased maintained?What are the responsibilities of mourners?How long is the mourning expected to last?How emotions should be handled?What are the prevailing beliefs with regard to the suffering of the bereaved?Should the mourners be socially excluded or included?How gender and age affect grief manifestations and mourning practices?Respecting mourning prac-