Culture and Death: a Multicultural Perspective

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Culture and Death: A Multicultural Perspective

Panagiotis Pentaris

Abstract

The factor of culture plays a critical role on how people perceive and deal with death, dying and bereavement. Each culture is unique and holds different and authentic beliefs and customs. This literature review will provide information from different cultural backgrounds among the population of Hawai`i regarding death, dying and bereavement (beliefs, customs, rituals, expectations, processes, etc.). The information aims to provide social workers and other helping professionals with appropriate knowledge and skills applicable to the culture they are working with. Thus practitioners can increase their cultural competence. Keywords: death, bereavement, NHPIs, social worker, Asian, Asian American, Hawai`i.

PART 1: DEATH, DYING, AND BEREAVEMENT ISSUES IN HAWAII

Death, dying, and bereavement are loss, the loss of his/her individuality, or of universal and unique processes that a bereaved system. A dying father, for everyone will experience eventually, both example, is grieving that he will not see from a dying person’s perspective and his daughter graduate. She, on the other through grieving for the loss of a loved hand, is grieving for the loss of her father. one. In both cases the person experiences Nobody can conceptualize and experience a great loss in his/her life, and the death, dying and bereavement in exactly experience is processed differently every the same manner. Even if the same person time. Grieving is also inevitable for both is experiencing another loss, different cases. We either speak of a person who is mechanisms and coping skills will arise. dying and he/she is grieving for his/her

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However the uniqueness of these Hawaiì is a multicultural state, significant life experiences, there are consisting of varied ethnicities, perhaps factors that can “guide” the way one is more than any other state. The cultures acting. A major determinant factor for which compose the Hawaiian population social workers and other professionals blend with each other, and values, beliefs such as psychologists, who practice with and customs blend as well. However, bereaved and/or dying systems, is culture. traditional death attitudes and customs are What are the cultural beliefs and values of kept. the dying patient? How far should one go Awareness is essential for social work to convince the family to bury the body or practitioners, and that could be identified donate its living organs to science, as by many different components, such as opposed to cremating it, which is what cultural awareness. Especially in a Asians and Buddhists have been doing in multicultural society such as Hawaiì, their family and in their culture for the social workers and other professionals in past century? the fields of death, dying and Different cultures perceive death, bereavement, such as in hospitals and dying, and bereavement in different ways, hospices, will become more effective if while different religions in the same they gain knowledge on how their clients-- culture influence those perceptions as who might differ vividly--perceive their well. Filipinos for instance, traditionally, situation/issue. For example, Native spend three days and nights at the Hawaiians do believe in communication cemetery where the body of the deceased with the deceased. Thus, if a rainbow is buried, out of respect for the person, a shows in the sky, they believe the dead belief which is different from other person speaks to them and it has a positive cultures. In other words, death attitudes effect on them. A culturally aware are different depending on the cultural professional will accept this attitude and background. Furthermore, culture itself will avoid conflicts, as in referrals to a has a great impact on the way people clinical setting. Being aware of those grieve. different perspectives, customs, values, beliefs, and principles the practitioner will likely be more effective to the client. Awareness is essential for social He/she will be able to build a rapport work practitioners, and that could be based on trust and probably choose an identified by many different approach, strategy or intervention which components, such as cultural will best fit the client’s needs, depending awareness. on the cultural background. Hawaiì is a special gathering place Kubler-Ross, in her book On Death and with its own unique culture. It is a place Dying (1969), refers to five stages one where several diverse cultures emerged meets through the grieving process. But and intersected over history (Kirch & she also states that grief is experienced Rallu, 2007). For one to fully understand differently, every time that it occurs. the cultural dimensions of death, dying Depending on many factors, the and bereavement in the State of Hawaiì, individual will not go through all the it is critical to first acknowledge and stages, or might start going through them understand those cultures that today in different order.

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constitute the “modern culture” of of the population. In other states, such as Hawaiì (Green & Beckwith, 2009). California, white people usually compose This article’s purpose is to examine and the two thirds of the population (e.g. provide information from different California: 76.75%) (U.S. Census, 2010; cultural backgrounds among the 2009; 2000). population of Hawaiì regarding death, In 1778, the population of the Native dying and bereavement (beliefs, customs, Hawaiians living in the islands of Hawaiì rituals, expectations, processes, etc.). The was rising up to approximately, 400,000- information aims to provide helping 600,000 inhabitants. Those were the professionals with appropriate knowledge people that were referred as to kanaka and skills for the culture(s) they are maoli (Native Hawaiians). During the 19 th working with. century though, their number dropped This paper provides a full 80%-90%. The major reason for this description of the population of Hawaiì. significant change was the diseases An overview of the population’s (measles, whooping cough, Hansen’s characteristics in the past and today is disease, smallpox, etc.) which were depicted, as well as its strengths, and the introduced to the kanaka maoli by their social and cross-cultural problems that the contact with foreigners (Hope & Hope, population faces nowadays. Additionally, 2003). In 1878, the general population of reference to death rates and death causes Hawaiì increased approximately 40%- is noted. Social work practice on 50%, out of which 75% were Native Hawaiian populations is examined from Hawaiians (Kirch & Rallu, 2007; three different perspectives: micro, mezzo, Kawaharada, 2003). and macro. Moreover, social work However, the number of “pure research and legal and ethical issues are Hawaiians,” as are called the Hawaiians also addressed. The conclusions drawn by with 100% blood quantum, has declined this paper and overall from the literature significantly to about 8,000 people today. review are depicted, and lastly The number of the people who are part recommendations are made, and future Hawaiians or consider themselves to be trends for implementations are discussed. Hawaiian, and live in Hawaiì is 225,000- 250,000 nowadays, the majority of whom COMPOSITION AND DEMOGRAPHICS live on the island of Oàhu (Kirch & OF THE POPULATION OF HAWAII Rallu, 2007). This part of the general Hawaiian population grows annually by The composition of the Hawaiian 6,000 people, more than any other race population varies in many different ways. living in the state. The different characteristics of the According to the new data from the kamaàina (native-born, ethnic or 2010 US Census, the number of people nonethnic Hawaiian) and the malihini living in Hawaii has increased during the (newcomer) lead to unique death past decade. According to the US Census attitudes, behaviors, beliefs about dying, Bureau, in 2000 there were 1,211,537 and bereavement processes and stages. people living in the state. According to The population of Hawaii comprises a the 2010 Census, 1,360,301 people living variety of descents and origins. Hawaii is in the State of Hawaiì (U.S. Census, considered the only state in the U.S. 2010; 2000). where whites compose just the one third

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As indicated in the Table, the majority country this number is significantly lower of the population of Hawaii is Asian alone (1.5%). (38.6%). Significant is also the fact that The U.S. as whole might be a racially the number of White people (24.7%) is and ethnically diverse country, but almost the same as the number of those Hawaiì is by data more diverse than the who identify with two or more races nation itself, and every other state in it. (23.6%), (U.S. Census, 2010). There is a unique character of Hawaiì which needs to be identified by the Disparities with the General practitioners working for its population. Population of the US The 2010 Census Bureau reported that Table: 2010 Population of the U.S. and the general population of the United the state of Hawaiì Based on Race and States has increased to 308,745,538 Ethnicity: Comparison residents since 2000. According to the U.S. 2010 Census data, which are the Population United Hawaiì most recent, racially, the biggest part of States the U.S. population is white Americans Total 308,745,538 1,360,301 (approximately 80.2%). Based on 2005 population (100%) (100%) estimates, on on the general population of Ethnicity the U.S., the rest are minority groups. White 80.2% 24.7% More specifically, 12.8% are Black or Black or 12.8% 1.6% African Americans, 1% are American African Indians or Alaska Natives, 4.3% are American Asians, 0.2% are Native Hawaiians and alone Other Pacific Islanders, 1.5% have two or American 1% 0.3% more races, and 14.4% are of Hispanic or Indian and Latino descent (U.S. Census, 2010). Alaska A simple comparison between the data Native alone of the general population of the U.S. and Asian alone 4.3% 38.6% the data regarding the State of Hawaiì Native 0.2% 10.0% can lead one to see the major differences Hawaiian from ethnic, racial, and cultural and other perspectives (Table). Pacific As for the general population of the Islanders U.S., white Americans compose the alone biggest part, as opposed to the State of Two or 1.5% 23.6% Hawaiì, where white Americans are the more races second largest ethnic group. Also, Asians Hispanic or 14.4% 8.9% alone compose only 4.3% of the general Latino population in the U.S., whereas in Some other - 1.2% Hawaiì that number grows to the race alone majority of the population (38.6%). Source: U.S. Census Bureau data, 2000, 2005, Lastly, in the State of Hawaiì 23.6% 2010 people identify with two or more races, while for the general population of the

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Hawaiì is marked by a great variety of for Hawaii residents was 81.7 years differences, such as the variety of (CDC, 2010; Xu, Kochanek, Murphy, & languages spoken and the Asian/Pacific Tejada-Vera, 2010). origin of those languages, which leads to a The Hawaii Department of Health more complex environment in which (DOH) has reported in 2009 on the 15 social workers and other practitioners are leading causes of death, 12 of which are called to adapt according to specific, diseases. According to Xu et al. (2010) the commonly multicultural, needs of their death ratios per 100,000 population in clientele. Working with issues such as 2006 were as follows: death and grief, and being competent to adjust to many different cultures, customs, Alzheimer’s disease 14.1 beliefs, and procedures, as well as Cancer 146.2 psychosocial and mind processes of the Diabetes 18.5 experience itself, cultural awareness Heart disease 140.2 becomes critical. Stroke and 39.6 Cardiovascular disease DEATH RATES AND CAUSES AIDS/HIV 39.3 Influenza and 11.6. To justify the importance of this pneumonia theoretical approach, death rates and causes need to be examined. As noted by Overall, in the year 2008, approximately Callahan (1999) adjusting one’s approach 7,350 deaths, including both inpatients to the cause of death may increase a social and outpatients, were reported in worker’s effectiveness. Causes of death Hawaii’s health institutions (Xu et al., vary a lot in Hawaiì, and mainly include 2010). natural deaths, accidents, illnesses and diseases, homicides and suicides. Suicides and Homicides Regardless of the cause, the happenstance In the year 2008, there were 129 of death will extend to bereavement as deaths by suicide reported, and an well. The significance of these experiences additional 42 deaths by homicide. Suicide cannot be diminished for any culture, but is a common risk behavior in youth in the they can definitely be viewed differently. U.S. overall, and in Hawaiì as well. A determinant factor that may lead a young Natural deaths: Statistics person to commit suicide is actions under According to data from Kaiser the influence of drugs or alcohol Permanente (KP) and the Department of (Nishimura, Goebert, Ramisetty-Mikler, Health and Human Services (DHHS) & Caetano, 2005). (2008), the State of Hawaiì groups certain In both suicides and homicides, the causes of death such as cardiovascular, bereaved experience a more complex influenza, and pneumonia as natural grief, blended with a traumatizing event to causes, and therefore limits its ability to their lives. The complexity of the associate exact death ratios with specific experience increases when culturally causes (Lim, 2009). Regardless of the grounded beliefs and values, such as barriers to identify natural causes, the spiritual or religious ideas about suicide, Vital Statistics Division of the DHHS come into play (Orbach, 1999; Mermann, indicated in 2007 that the life expectancy 1991).

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Accidents which leads them to existential questions. Deaths by accident constitute one People who are grieving for their beloved more significant event, and an unexpected ones are challenged in their own crisis in the family’s life. According to existence; they face the fact of human data from DHHS, in the year 2008, there mortality. People who are dying may were 383 deaths by accident, and in 2007 focus on spirituality and religion for there were 10.3 deaths by motor vehicle salvation and forgiveness. The human accidents in Hawaiì, as reported by need for belief in a superior power is often health institutions (CDC, 2010). emphasized during the death experience Natural Disasters (Canda & Furman, 2010; Tomer, Eliason, Hawaiì is one of the states which is & Wong, 2007). prone to Natural Disasters, and it has a Regardless of the universal character history with tsunamis (Kirch & Rallu, of spiritual, religious, and existential death 2007) as well as hurricanes. Natural beliefs and attitudes, diverse religions disasters, as well as suicides, homicides, perceive the experiences of dying, death, and accidents, may cause sudden, and bereavement in different fashions. unexpected losses, promoting a crisis The composition of the population of event for the people who are experiencing Hawaiì does not only include various them (Kubler-Ross, 1979). However, each cultures, but is also characterized by person, according to cultural, racial, and diverse religious orientations. The latter ethnic background, perceives the becomes a unique factor which impacts phenomena and events differently (Sue & one’s perception of death, dying, and Sue, 2008). bereavement, for it has an impact factor on his/her culture. EXISTENTIAL , RELIGIOUS , AND SPIRITUAL ISSUES IN DEATH , DYING , AND Christianity BEREAVEMENT Christians believe that death inevitably will happen to all, and that its Different religious and spiritual experience will commence an afterlife. orientations lead to different behavioral “Though you have made me see troubles, patterns and attitudes on death, dying, many and bitter, you will restore my life and bereavement. People in near-death again; from the depths of the earth you instances or chronic diseases, such as will again bring me up. You will increase AIDS/HIV, seek understanding and my honor and comfort me once again ” meaning through various religious (Psalm 71:20-21). statuses (Braun, Pietsch, & Blanchette, In Christianity, it is believed that 2000). “Spirituality refers to a universal people live a short time on this earth, to be and fundamental human quality involving “judged” at the time of death by God and the search for a sense of meaning, assessed on their lifestyle. An eternal life purpose, morality, well-being, and awaits all individuals, who are placed profundity in relationships with ourselves, either in heaven or hell, depending on others, and ultimate reality, however their conduct on earth. Heaven is understood” (Canda & Furman, 2010: characterized by constant joy and p.59). happiness, but tortures and punishments Individuals who are dying, and await everyone who enters hell. Catholics, bereaved people, are experiencing a crisis, however, introduce one more state of

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afterlife: purgatory (Canda & Furman, Buddhist clergy support the 2010). The person in purgatory has acknowledgement of death, and challenge escaped hell, and restitution of his/her Buddhists to be prepared for their own sins is made in purgatory, which will demise. They recommend the followers to eventually lead to the person’s entry into live a calm and happy life, showing love heaven. The Church emphasizes the to all living creatures and to nature, importance of a life according to the Bible, because the way that they have lived will in order to assure one’s way in Heaven. come back like a “boomerang” to affect The body of the deceased Christian their karma for their rebirth (personal can either be buried or cremated (even communication, January 19, 2011). though cremation is more welcome within NHPIs, as opposed to the Mainland). Confucianism In Confucianism, death is something Buddhism that goes outside the followers’ sphere of There are various forms of interest. People in Confucianism believe Buddhism, such as Theravadin, that to get to know life on earth requires a Mahayanist, Zen, etc., which are lot of work, and no time can be allocated represented by the population who live in for death (Long, 1975). Death however is Hawai`i. The most common form, not annihilation for people in this religion. however, is Mahayanist Buddhism which They believe in Heaven, but in a different is represented by people from China, fashion than other religions. Heaven is Japan, Korea, and Vietnam (Canda & just a high spiritual presence that human Furman, 2010). All forms of Buddhism beings know of, and have the need to have four basic beliefs which apply to believe in. existential issues regarding death and bereavement. Those beliefs emphasize Taoism/Daoism that “…human existence is characterized Individuality and spiritual life are the by suffering…that arises from main focus of Taoism, one of the most inappropriate desire that clings to what we ancient Chinese religions (as is have…This suffering can cease by Confucianism. “Since life and death are eliminating inappropriate desires. . . . each other’s companions, why worry egotistic desire can be stopped by about them? All beings are one” (Chuang- practicing a disciplined way of life, based Tzu). In Taoism, death and life are two on correct perception, conduct, and aspects of the same continuum. Death is meditation” (Canda & Furman, 2010: just a transformation from the state of p.145). being to the state of non-being. Human Death, for a Buddhist, is not the end beings need to accept death the same way of one’s life, but the death of his/her they accept life, and conceptualize the body. The spirit remains and “travels” to importance of both. infinity until the time it will regenerate in a different reincarnated form. In other Agnosticism/Atheism words, Buddhism believes that life does A minority group of this world is not end with death, but it carries on to composed of people who do not believe in different forms according to the any deity (atheists) or who feel that they deceased’s accumulated karma (cause and cannot be certain whether God exists effect) (Long, 1975). (agnostics). Some of these live in Hawai`i.

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They do not believe that a deity created views a dying person as a thinking and humans, but the opposite: that humans feeling human being rather than a thing created deities. The individuals called which must be dealt with, thus agnostics, which means “with lack of contributing to the method of hospice care knowledge” and comes from the Greek α- where emotions are cared for as well as γνωση , do not believe in an afterlife, but physiological needs. At the same time, only that death leads to non-existence. while working with dying patients, The deceased has disappeared and no Kubler-Ross analyzed what goes on in longer is aware of the bereaved person’s their minds. existence, and hence grief becomes In her experience-oriented research, pointless (Callahan, 1999). Kubler-Ross (1979) found five specific emotional and mental stages that are Other Religions and Movements consistent with almost all patients, all of Many other religions are in this which occur because they're emotionally world, and each one of them has beneficial in one way or another. Usually developed its own views on death, dying, the stages require a good amount of time and bereavement. Of course there are to experience, as with a person diagnosed certain similarities among religions and with a terminal illness. In sudden, sub-religions, such as Orthodox and unexpected deaths there simply isn't Catholics. Islam, Hinduism, enough time to be emotionally and Zoroastrianism, and Judaism are other mentally affected in too many different religions which are seen in Asian and ways (Kubler – Ross, 1979). African populations mostly. Among the These five stages don't usually follow Hawaiian population the number of any particular order, and each can be Muslims is growing, but it is still small experienced more than one time. The (personal communication, February 27, stages are: denial and isolation, anger, 2011). bargaining, depression, and acceptance. All these phases are the same ones that CULTURAL EXPRESSIONS REGARDING dying persons, specifically those in DEATH , DYING , AND BEREAVEMENT terminally illnesses, in the Hawaiian culture go through as well as other The “modern Hawaiian” culture is cultures. Moreover, these five stages, as composed of several different ethnic well as the modern hospice movement, cultures, and thus many different customs, are effective in grief therapy and beliefs and values are included in the counseling for the bereaved till today, in general dimensions of death and all the hospices or any other settings that bereavement. However, there are those are applied (Kubler – Ross & universal aspects of the process of grieving Kessler, 2005; Dame Saunders, 2002; and internationally accepted emotional Callahan, 1999). stages of the dying person. Elisabeth Kubler-Ross (1979; 1975) Native Hawaiians was a pioneer in the psychological field of No matter how hard Native Hawaiians death counseling, and Dame Cicily try to maintain indigenous rituals and Saunders (2002) was the founder of the beliefs, the generational inheritance would hospice movement. Both significantly be influenced by and influence other contributed to start a movement that cultures (Kirch & Rallu, 2007). To fully

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understand the different worldviews on each other and promote well – being of death and bereavement, one should be both individuals and family as a system. aware of the cultures alone, the multi- Storytelling is the main way of bringing cultural environment and the interactions up memories of the deceased and between the two. “keeping the spirit alive” through Despite the numerous different narratives, due to the belief that the body cultures on the Islands, the population of is dead but the spirit of the deceased is still Hawaiì and especially Native Hawaiians there (Green & Beckwith, 2009). view death and the grief process as The Hawaiian culture, including something self-sufficient time-wise, to NHPIs, highlights the fact that when express goodbyes and grace to the someone dies, the deceased’s spirit deceased. It is a process that has its own remains in the world and escorts the pace and no one can hurry that. Gods. Traditionally, the body would be Historically, Native Hawaiians expressed buried following certain rituals and grief and their sadness due to a loss in customs. Years after it would be unburied several ways. These included wailing and the bones (as emphasized in the (uwe ), chanting rituals ( oli ), and physical Christian custom of relics) as well, were degradation of the mourner or other acts perceived as the remainders of the person of unusual grief 1, burial practices, and the who passed away. Due to the importance ohana (Ushiroda, 2008). These customs the Hawaiian culture gives to the bones of have today been adopted by Guamanians the dead person, as will be discussed later, and Samoans living in the state. cremation is not acceptable most of the Until today, there have been many time, and burials are conducted instead changes in the way people cope with the (Han, Collins, Clarks & Garland, 1986). loss of a loved one. In the past, Hawaiians When the body is still in the house used to remain in the house for days after where it will be prepared for the funeral the death of the member of the family, ceremony, no one is allowed to touch it, and were “talking story 2” to remind because of the belief that the body is now themselves of memories of that indi- empty and it can take the living person’s vidual. Those days that they remained in mana (divine power). The deceased is the house, no one but a family member respected in many ways and the process of could go in. (Ushiroda, 2008). its burial, as well as the procedure of the The O`hana (family, including goodbyes to that person who is dead, extended family) process and storytelling takes as much times as needed (Ushiroda, have been historically, and still are, two of 2008). the major ways people in Hawaiì express Native Hawaiians believe that every their grief. Part of the Hawaiian culture person is full of mana , which at death indicates a family oriented dimension of resides in the iwi (bones). The iwi have to living, which leads to the O’hana process. be buried in the ground, in order to impart Members of the same family supporting their mana . In ancient Hawaii, Natives would bury the bodies in a couple of 1 Such as tattooing the tongue; painful and permanent. different ways. Some people would bundle 2 By this term, Hawaiians mean sharing stories, the body, by bringing the knees up to the reminiscing, and exchanging information about feelings chest, in the ground. Common was as well and emotions. “Talking story” is an essential part of the Native Hawaiians and Pacific Islanders (NHPIs), which the removal of the pala (flesh and organs) through time has extended to other cultures in the State and their deposit at the sea, while the of Hawaiì .

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bones would remain in the care of the establish and maintain proper relations family (State Historic Preservation with the spirits. The ancient Hawaiians Division [SHPD], 2011). Other times the believed these spirits, who pervaded the longer bones of the body, and the poò world and shaped events, had the power (skull) would be deposited in a cave or a to inflict injury if directed or if angered by crevice. Lastly, some Native Hawaiians the breaking of their kapu (system of would bury the bodies around their land rules), but could be approached and in order to maintain physical closeness persuaded to act in one's behalf (SHPD, 2011). (Kamanaòpono, 1999; Han et al., 1986). According to the SHPD (2011) of the Department of Land and Natural Resources (DLNR), all these deposits and burial sites have remained to today, along Native Hawaiians believe that with the Native Hawaiians’ belief that the every person is full of mana , family members have the responsibility to which at death resides in the iwi malama (care for) na iwi kupuna (the bones (bones). of the ancestors). The foreigners’ influences in the State were accompanied by the identification of several burial sites on the islands, with a Nowadays, Native Hawaiians strongly major example the Honokahua location on believe that a death of one person Maui. Numerous buried iwi were connects that person to the family excavated that time, and Native members who have died in the past. Hawaiians started rallying against it. In Death for the Native Hawaiians has 1988 rallies took place at the State Capitol become a way for the deceased to move to of Oàhu, and Hawaiians finally a higher level after earth and thus Native accomplished to draw attention and make Hawaiians do not mourn death. Han et al. the excavations stop (SHPD, 2011). Since, (1986) explain that, “reunion with Burial Councils 3 decide for relocation or ancestors was considered comforting for preservation of the iwi found. the deceased, as well as the surviving Religion was and still is the paramount members of the society” (p.21). aspect of Hawaiian life, permeating every The living are believed to daily activity, every aspect of secular communicate with the dead through signs, affairs, and every significant event, such such as accidentally dropping something as birth, marriage, death, and agriculture. in front of the deceased’s picture frame, or Also important are the regular calendar via visions, which help the family feel celebrations to ensure the peoples' more comfortable with the death. The prosperity and well-being. All activities warm days, the sunshine, rainbows and are accompanied by appropriate rites, representations of sharks or turtles – religious ceremonies, and prayers to especially if these are the family’s aumakua (totem) - convey a positive message and a connection with the spirit of the deceased 3 A mixture of representatives from regional Native (Ushiroda, 2008; Kamana’opono, 1999). Hawaiian communities and representatives of large landowner interests. “Part of the island burial Another concept of death in the council’s duties include educating landowners as Hawaiian culture has been mostly to the cultural beliefs and views regarding burials influenced by Polynesian rituals and encountered on their lands” (SHPD, 2011, p.3).

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beliefs. It is known as uhane (night Death in the Hawaiian culture can be marchers). It was believed, not necessarily expressed through art forms, such as by everyone, that as soon as one went to dancing. Hula is a unique way of sleep, his/her spirit slipped out of the expressing one’s feelings and emotions in body and took long walks, returning Hawaii. Hula began as a sacred ritual, and before the person was awake again. The has over time flourished into an art form. uhane, it was believed, is the part of one’s Originally, it was a type of worship in self which can verbally communicate with religious ceremonies, and was performed the spirits of the dead,. Such experiences, to give thanks to Hawaii’s ancient Gods though, are only remembered as dreams and honor its chieftains. Later hula, by the individual. chants, and songs moved from the temples Unless the uhane of the person had into the secular world. Accompanied only completed socially acceptable acts and by voice or percussion instruments, male had been welcomed to the family, after — and subsequently, female — hula the person’s death the spirit remained on dancers use their bodies to express the the islands as a ghost, wondering around wondrous legends of the Hawaiian Islands to fulfill its purposes. Until today, there (Green & Beckwith, 2009). Every hula are still beliefs in ghost activities, and movement has a specific meaning. kahunas (traditional Hawaiian priests) are Different gestures symbolize flowers, invited to bless the establishment and animals, even conflict and war. make the ghosts leave. Many stories of ghosts and spirituality have been shared OTHER PACIFIC CULTURES with Carroll (1996) by either Native Hawaiians, or foreigners who are visiting The multi-ethnic environment of the the islands. The House on Kuùkama Pacific needs to be explored as far as Street, on Oàhu is one of them. The beliefs and values on death and dying go. tenant of one of the bedrooms, after he The Pacific Islander population consists of experienced numerous of abnormal events many different ethnicities and races from which included a shadowy male figure around the Pacific; however, only two of and a laugh in his ears, found out that the them, Guamanians, and Samoans are landlord’s husband has died in the exact discussed below same bedroom (Carroll, 1996). A major funeral custom nowadays, Guamanians or Chamorro 4 which comes from an influence from the Chamorro people’s beliefs about death Japanese culture, is for the people who and dying resemble those of the Native attend the ceremony to give money along Hawaiians, either due to coincidence, past with a funeral card, as opposed to flowers. interchange, or acculturation of the In that way, people contribute to the Guamanians who have migrated to the expenses of the funeral and the expenses islands of Hawaiì. of the lunch or dinner that will take place An estimated annual number of deaths afterwards, as an indication of among Guamanians is 4.64/1,000 people appreciation for the loved one who has (U.S. Census, 2010). Death is perceived as passed away and appreciation to the a superior state of non-being. It is believed people who honor him/her (Green & to be part of human nature’s development. Beckwith, 2009; Ushiroda, 2008).

4 The Chamorro are the Native people of Guam.

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Nonetheless, the grieving process becomes arrived to do so (personal communication, tough for Guamanians, in the same April 5, 2011). fashion as it is for Native Hawaiians The Samoan culture has a unique way (Perez, 2005). Family is the strongest of viewing death and dying. Both are supportive system when death occurs in respected life events which are believed to the family. Grief, as it is experienced and offer to the family knowledge, spiritual expressed by Guamanians, could be power, or motivation for life. A dying characterized as prolonged or abnormal person, as with the Native Hawaiians, is from a clinical perspective. Chamorro believed to have special powers (mana for people prefer to honor the deceased over Native Hawaiians) right before the spirit the long run, and thus their grief never leaves the body, and the spirit remains in ends. There are memorials on an annual the world for its protection. Even after the basis, which include many mementos at a spirit’s withdrawal from the body, the cemetery ceremony. Grief is encouraged latter still retains special powers. Thus among family members, as well as organ donation suggestions might offend a expected, especially when it regards youth Samoan family, and also autopsies are grieving for the loss of an elder. Many avoided (Ofahengaue et al., 2008). families talk story about the deceased and Serenades are common among his/her visits to them through scent, Samoans to the dying person. These have touch, or appearance (Perez, 2005; a dual meaning, first to show respect to Pobutsky, 2001). the dying person, and secondly to comfort the relatives who are grieving for the Samoans. upcoming loss. When the person passes The Samoan families in Hawai`i are away, it is common in the Samoan culture extended ( aiga potopoto ), as in Samoa, that the body is buried on the family’s each of which is entitled to a chief. Some property, as a constant reminder in the Samoan populations in Hawai`i also own lives of the survivors (Tauiliili et al., their land, which is essential to death 2001). experiences and burials. A chief in the Taliga toga (the practice of exchanging family is the tulafale (orator, “talking fine mats) is an essential ritual when chief”), who is the most respected someone dies; the survivors create mats member. The chiefs in the families are the with all the memories of the deceased to ones holding and carrying on the family’s keep their spirits alive and present as a history and traditions, while at the same reminder (Ritz, 2006). It is also a time, those are the ones who will pass reciprocity practice among the family over the news of a death and a burial to members after the death of a loved one the rest of the kinship (Ofahenguaue, (Ofahengaue et al., 2008). Halaevaly, & Meripa, 2008; Tauiliili, Delvan, & Browne, 2001). Other Pacific Islanders. Additionally, chiefs are the ones who will make the significant decisions when The Hawaii population is composed someone is sick and/or is dying. For from more cultures from the Pacific, such example, a Samoan mother would not as Chuukese. There is a common and sign the paperwork for her son’s surgery, mutual aspect among the majority of no matter the severity of the situation. On those cultures, which is a family-oriented the contrary, the chief of the family grieving process.

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Overall, Pacific Islanders embrace Chinese. the family’s support when experiencing a Mui Hing (2002) in her study on a death, and always respect the elderly. “good death” for the Chinese population Bodies, as with Chukeese population in in general, identified seven elements 5 that Hawaiì, are preferably buried and no constitute this concept. As long as the organ donations are welcome. Instead, the dying person knows that he/she is dying, body must remain untouched for its is capable of maintaining hope, is able to powers to remain as well, and also for the manage pain, has feelings of personal family to be able to “interact” with the control over his/her life, feels connected spirit of the deceased (Kirch & Rallu, to her/his supportive systems, and has 2007). accomplished preparations for “departure,” then the dying person is more likely to accept his/her own death ASIANS AND ASIAN AMERICANS and hence, experience what Chinese IN HAWAII perceive as a good death (Mui Hing, 2002). Asians constitute 38.6% of the Religious affiliations and spirituality population in Hawaiì (U.S. Census, help the dying person in the Chinese 2010). That having been said, death, culture to move on to the acceptance of dying, and bereavement perspectives of his/her own death (Canda & Furman, the general Hawaiian population have 2010; Mui Hing, 2002). However, in been influenced through time from the Hawaiì the majority of the Chinese Asian beliefs and customs (Ushiroda, population has no religious affiliations, 2008). Native Hawaiian customs and while those who do are followers of either values remain, but do not dominate the Taoism or Confucianism. A small number whole population. A blending and are Buddhists (Swartz, 2010). merging process has been taking place In the Chinese culture, funerals are through history, of a multi-cultural point mostly large and elaborate; the status of of view in the general Hawaiian the deceased plays a critical role in what population. and how many possessions will be buried Asian families are, in general, family- with him/her, in order to attain successful oriented and traditionally hold onto entrance to the afterlife (Pang & Lam, certain beliefs and value systems, such as 2002). Chinese tend to build their own gender roles. For instance, it is expected altars on their properties, to respect the for an Asian widow to publicly and deceased ones. Additionally, there is the privately mourn for her deceased husband “Tomb-Sweeping Day” on April 5 th , when longer than any other ethnicity does (Pang visits to the burial places are necessary to & Lam, 2002). Also, children of Asian honor the ones who passed away. Finally, cultures and Asian American descents do “Ghost month” occurs from late August not get exposed to the experience of death until late September, when it is believed prior to the incident. Thus, the children’s that the spirits of the dead come to earth. perception of death is more physiological Traditional Chinese families in rather than psycho-emotional (Yang & Hawaiì struggle when they have to bury Chen, 2002). someone who dies during that month.

5 These seven elements could be true for other cultures as well (Mui Hing, 2002).

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Commonly and traditionally, if someone their ancestors. People dance to dies during that month, then the burial traditional Japanese music, which has to will take place the next month (Mermann, be “happy music,” for the ancestors’ souls 1991). to come out. Japanese believe that the souls of the people who have passed away Japanese. only come out during the night and to Hattori, McCubbin, and Ishida (2006), “happy moods” and music (Yokomizo, in their study on “good death” in the 2001). Japanese community of Hawaiì, found that the concept of the dying process is Filipino. essential to the death experience, the Regardless of their devoutness during bereavement process and the dying their lifetime, when death occurs Filipinos process itself among Japanese. The become religious, specifically following concept of a good death is an omen for Catholic rituals and customs, and embrace family satisfaction and a positive spirituality (Shimabukuro, Daniels, & bereavement process. DÀndrea, 1999). A strong belief is that In the Japanese culture, the family death is God’s decision and act, and if members are the ones who will make all someone has strong faith then death can the important decisions regarding end-of- be thwarted. If the latter does not happen, life issues, and also the dying person is the bereaved may start feeling guilty for protected from the hearing of bad news. not having had a strong enough faith to As long as the latter is accomplished, it is have saved the deceased (Braun & believed that a concept for a good death Nichols, 1997). has been set as well (Bell et al., 2009; As opposed to men, women in the Hattori et al., 2006). Filipino culture grieve openly, which As noted earlier regarding Hawaiian depicts their love for the person who has customs and beliefs, distribution of money passed away, and at the same time during funerals as an indicator of respect indicates to God how heavy their grief is for the deceased is emphasized in for the one they have lost. When a death Japanese culture. The money is given to occurs in a family, all friends and family the family members in order to cover the members are expected to attend wakes; expenses of the ceremony and/or burial. otherwise it is considered an offence. The Bon-Odori (Bon Dance) is a Japanese number of people at the wake illustrates tradition, which comes from Buddhism in the deceased’s life quality. Filipinos China. Bon means welcoming the souls of believe that the body of the dead should ancestors and holding memorials for them remain whole, and thus cremation is (Yokomizo, 2001; Van Zile, 1983). Every seldom a choice. At the deceased’s house, year, during August or September in a Rosary session is held every night after Hawaiì, Bon festivals takes place, under his/her death, in order to help his/her the Young Okinawas of Hawaiì 6 (YOH) entrance to heaven (Braun & Nichols, leadership. The festivals last for a week, 1997). The length of these sessions and are the place and time when all the through time, vary based on the family’s relatives of the family will gather to honor will (personal communication, March 11, 2011). 6 Information available at: http://www.bondance.com/2010/09/young- okinawans-of-hawaii/

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Korean. each other in several ways, such as Death in the Korean culture has psychologically, socially or financially. several dimensions, such as the end of a Additionally, Native Hawaiians and painful period, the dispersion of existence many others have a strong belief in God. for the deceased, the transmission to an Spirituality, as well as religion, is a afterlife world, and finally the returning to determinant factor in their lives (Canda & “the original place, where all life began” Furman, 2010; Kamana`opono, 1999). (Kyung Rim, Myung Ok, & Jeong Sun, That being said, Church/Temple becomes 2005). Common beliefs among Koreans an asset for the individuals and families to are ancestral spirits and afterlife. The overcome a loss of a loved one. Buddhists latter is mostly influenced by Buddhism. for example, cremate the bodies of the Adult children are usually a great dead, while the first seven days after death influence on their parents and/or elder are the most important regarding funeral members of the family regarding end-of- practices and mourning; prayers are said life decisions. The main decisions are during a 49-hour funeral period, that the made by them as long as they are the deceased’s spirit can receive help to caregivers for their parents and elderly reincarnate. (Eunjeong & Berkman, 2010). Lastly, the The Catholic funeral service, on the social status of the deceased is essential other hand, is called the Mass of the regarding on the period of time that the Resurrection. During the mass, the life of bereavement and mourning will last; the Jesus Christ is compared to the higher the status of the deceased, the deceased’s, and a final graveside service longer the mourning period (Kyung Rim accompanies the end of the funeral, as a et al., 2005). farewell to the deceased. Eulogies are less common during the mass; however, they RELIGION AND THE are welcome prior to that; during a wake POPULATION OF HAWAII for instance (Canda & Furman, 2010). Additionally, mourning is supported by After the death of a loved one, the Church and the community as a individuals and families try to find whole. As in the Orthodox Church 7, strengths that will help them adapt to the special prayers for the deceased are held new circumstances, avoid prolonged grief, during the funeral, that God will forgive and eventually re-enter society in terms of his/her sins. Also, the Orthodox Church common activities. Adaptation to a death holds a special vigil over the deceased, is a critically significant event to all called the parastasis of panikhida, during individuals, and coping skills and the Mass; the funeral service includes mechanisms, such as ways of grieving, much Bible reading and chants as well. have to be found either within the Spirituality and religion are both great bereaved individuals/systems, within strengths. The people of Hawaii have personal and societal informal systems, or strong bonds with the deities, regardless of within formal ones (Orbach, 1999; their religious orientation, and their belief Callahan, 1999). gets stronger when death approaches. The system of Ohana in the Hawaiian Hence, supportive systems are developed culture is a major component when it with religion and church. comes to strengths after a loss. The members of the family are supportive of 7 Although it is small, there is an Orthodox presence in Hawaii .

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A MULTI -ETHNIC there have been a few influences over STRENGTHS PERSPECTIVE history on certain cultural dimensions, such as funeral practices (Canda & An essential strength of Asian and Furman, 2010; Green & Beckwith, 2009; Pacific Islanders, which include the Braun et al., 2000; Callahan, 1999). Native Hawaiians, is their respect for their The loss of one’s cultural identity due own diversity, whether it is cultural to acculturation and enculturation is the diversity, or ethnic, or spiritual, or strongest and most challenging issue religious (Green & Beckwith, 2009). They among the general population. Each value their diversities as strengths. Group culture within the state influences and is orientation and the feeling of Ohana are influenced by all the others (Sue & Sue, present, individual orientations may 2008). To that extent, within time certain sometimes also help overcome the grief traditions, customs, values, and beliefs over a lost loved one (Sue & Sue, 2008; may diminish. Kubler-Ross & Kessler, 2005; Callahan, 1999). Risks of the Grieving Process A great difference between Native “Grieving is a normal life process—an Hawaiians/Pacific Islanders, and Asians adjustment reaction to a loss. No specific living in Hawai`i, is the hierarchical precautions are warranted” (Kubler – relationships. In all the Asian cultures, Ross & Kessler, 2005, p.12). However, the hierarchy within the family system and grieving process might come across with the household is a critical key for success. certain circumstances which will In contrast, many of the Pacific Islanders complicate the process itself. These have chiefs, who make many important circumstances may involve the loss of a decisions (e.g., end-of-life decisions). child, or the loss of a loved one due to an However, these hierarchical relationships accident or homicide, for instance (Teno Asians have in their families help keep the et al., 2004; Howard & Scott, 1965). bonds well formed and structured among When a complicated case of grief takes the members, with clear identifications of place, different and extreme responses to each one’s responsibilities. Furthermore, the loss can be observed, depending on the in a death experience, where preparations individual's capacity for coping, personal for death have to be made, in such resiliency, and support system. For cultures it seems easier due to example, if the individual feels isolated, responsibility allocation within the family he/ she may be at greater risk for severe system (Sue & Sue, 2008). depressive symptoms or a suicide attempt. Alternatively, if the survivors feel rage or POTENTIAL PROBLEMS AFFECTING anger over the loss, there may be a risk of THE GRIEF PROCESS harm to others (Just, 2008; Skelton, 2003). Another risk exists concerning the Acculturation treatment of complicated grief. Such Different cultures in the state of circumstances might be chronic, Hawai`i still hold tight to their cultural prolonged grieving or unexpected loss beliefs. Native Hawaiians, Samoans, and (Kubler – Ross, 1979; 1975). These Guamanians believe in legends and determinants complicate the grieving superstitions to make meaning of the process due to the violent and unexpected significant events in their lives. However, nature of the loss. Two other factors that

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might impact and complicate more the to the right of the person who is dying, to grieving process include the type of end his/her own life, by filling in a request relationship the individual had with the form, and having a witness for it. Lastly, deceased, and the resiliency of the HB512 relates to “palliative care,”and individual. emphasizes the rights of the bereaved Those circumstances noted above have members of a family or friends. Palliative a universal effectiveness. The general care should be covered in one’s health Hawaiian culture keeps the family insurance as long as it is prescribed by the cohesive, and thus a strong informal physician. support system is created and maintained After the Honokahua incident, when through time, which allows the bereaved people rallied to assure that the relocation individuals to have several channels of of their ancestors’ iwi would come to an emotional dis charge and to that extent end, the Hawaiì State Legislature and the improvement of their well – being at the Governor at that time (1988) enacted Act given situation (Kubler-Ross & Kessler, 306. This act amended Chapter 6E of the 2005; Tone et al., 2004). Hawaiì Revised Statutes, and much more protection for unmarked burial sites was The Influences of Social Policies attained. The Act 306 created the Burial Death can be experienced, not only Sites Program to oversee the imple- from an individualized or a family mentation of new laws. Additionally, five system’s perspective, but also from the island burial councils were developed to community’s point of view. The process indicate proper treatment of the burial of dying has been influenced by policies, sites that had been found till that day, and which affect programs and services for the that would be found in the future. The Act population of Hawaiì. The same happens set penalties up to $10,000 per burial for with the process of bereavement. unauthorized action (i.e. excavation). HB1453, and HB163 are essential to In 1990, the federal Native American formally indicate “legal and personal Graves Protection and Repatriation Act relationships” in the State of Hawaiì. (NAGPRA) was passed. This Act Recognizing those relationships and required that all the museums and other putting them in a legal framework, is institutions should allow Native beneficial for relatives when the time for Hawaiians (and other natives) to end-of-life decisions comes. HB1165, repatriate skeletal remains, burial goods, which relates to “compassionate passing” and items of cultural patrimony to the and is influencing the end-of-life decisions lands they originated from. of the person who is experiencing the imminent death, highlights the right of the Hospital Policies and Procedures. dying person to fill in an end-of-life form The settings where policies influence and get a prescription of medication to death, dying, and bereavement issues and end his life. Additionally, in the latter bill, procedures are mainly hospitals and the importance of constructing wills, hospices. From the social work contracts, and other agreements is standpoint, a major difference between the underscored. two is that within a hospital setting, social “Death with dignity” is a subject work is a secondary service, whereas in a related to HB1383, HB1165, and SB803, hospice setting it is usually a primary in the State of Hawaiì. Emphasis is given

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service (Zerzan, Stearns, & Hanson, death, and is used for death registration 2000). through the DOH. The funeral home Many deaths may occur during takes care of the death certificate (DC), hospitalization, and furthermore, and ultimately the official DC is generated bereaved people may fill in hospital by the DOH. In cases of organ and body rooms, surgery lobbies, or the intensive donations to medicine, there are various care unit (ICU). According to CDC different policies in every hospital setting. (2010), twelve out of the fifteen leading The only common policy of the hospitals causes of death in the State of Hawai`i, is that, as long as the death is imminent, are associated with illnesses. Also, the staff of the hospital needs to be suicides, accidents, and other causes may notified in advance for the intentions of lead an individual to the hospital, dead or the person who is dying. alive (CDC, 2010). All the policies explained above, are In every organization and institution common in the majority of private and there are specific policies and procedures public hospitals in Hawai`i. To that that need to be followed under certain extent, despite the different cultures, the circumstances. When someone dies at a procedures people will have to go through hospital while an inpatient, there are are the same. Sensitivity regarding cultural certain steps that have to be taken. The aspects is generally shown in cases of first thing that may have to be done is to imminent death; hospital personnel may have the person named by the deceased as permit the family members to spend the next of kin to formally identify the nights at the hospital, in the same room as body. The same person, next of kin, may the patient, or waive other general policies also allow for a hospital post-mortem (Pobutsky, 2001). examination, if the death cause has to be Last but not least, some hospitals confirmed. 8 provide support and advice services. Unless it is removed directly from the Although it is probably helpful to start hospital floor, the body is kept in the with the things that need to be done when hospital morgue until it is collected. someone dies, family members and/or Collection of the body can be done by friends who are taking care of the family members, friends who have been procedures may neglect significant identified by the deceased, or most feelings of grief during the process, which commonly by a funeral director who has may lead to ineffective coping been contacted by the family. If the latter mechanisms. The death has occurred is the case, unless immediate cremation already and, instead of conceptualizing will be done, after embalming the funeral the facts, or maybe at the same time as director will keep the body in a chapel of that, they are trying to go through all these rest until the funeral takes place. proceedings. Of course, not everyone can The possessions of the deceased are successfully go through them without secured by the hospital staff members, and support. Advice services are provided in are given to the family members, if some hospitals, in order to help family present, after the death. The doctor also members and/or friends to accommodate gives the funeral director a medical accordingly after death. However, diverse certificate, which explains the cause of cultures perceive such services differently. For example, the Chamorro people are 8 In the State of Hawaii, under certain intense in their feelings of holding circumstances an autopsy may be required by law.

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everything in the family setting, and not promote those standards (Hepworth, being receptive to such services. Rooney, Rooney, Strom-Gottfried, & Larsen, 2010; Toseland & Rivas, 2009; “You matter because of who you are. Garvin, Gutierrez, & Galinsky, 2004; You matter to the last moment of Strean, 1978). your life, and we will do all we can, Grief support, social case work, not only to help you die peacefully, psychosocial therapy, family therapy, but also to live until you die.” group therapy, the ecosystems perspective, (Dame Cicely Saunders, founder of and palliative care are a few of the the modern hospice movement) approaches at the micro and mezzo levels which have been effective with the population of Hawaiì (Ponterotto, Hospice Policies and Procedures Suzuki, Manuel Casas, & Alexander, Hospice is a philosophy of care which 2010; Chang & Ng, 2002). However, the accepts death as the final stage of life. diversity of the state’s population requires Family members and/or friends will have a diversity of methods as well, when to go through similar processes as in a coping with death issues, and hospital setting, while death occurs. bereavement (Ponterotto et al., 2010; Sue However, hospice care is developed to be & Sue, 2008). sensitive by nature and provide support Social work practice at a micro and/or and quality of life services to both the mezzo level is provided to individuals and dying person and the family system family systems who experience unique (Zerzan et al., 2000). situations and face personal difficulties, such as death experiences and PART II: SOCIAL WORK PRACTICE bereavement, with which they are not able AND THE POPULATION OF to fully cope (Collins, Jordan, & HAWAIÌ Coleman, 2010; Breen, 2010; Evan, 2009; Woods & Hollis, 2000). Practitioners of MICRO AND MEZZO LEVELS OF SOCIAL social work in the State of Hawaiì have WORK PRACTICE AND THEIR been and continue to be challenged due to EFFECTIVENESS the ever-changing composition of the population. A variety of methodologies The diversity and the differences within has been used through the years with the State have led the profession of social Asian Americans and Asians who live in work to urge multicultural counseling the State of Hawaii (Chan et al., 2005; practices and/or adjustment of Western Forisha, Wright, & Tucket, 2005; Chang practices, methods, and approaches with & Ng, 2002). However, the effectiveness diverse clientele. The NASW Hawaii of the approaches is changing depending Chapter “is dedicated to promoting the on the evolution of the culture’s quality and effectiveness of social work components. “Ethnic and other group practice in a state rich with diversity” values and traditions are not static, but (NASW-HI). The profession of social ever-evolving” (Woods & Hollis, 2000: work is entitled to this dedication, noted p.58) based on a variety of factors, such as by the NASW Hawaii Chapter, and its how long an individual or a family has practitioners are using methods and been in Hawaii. approaches that from various perspectives

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It becomes impossible for social Palliative and hospice care. workers to adequately inform themselves Palliative care refers to any care that about all the cultures they are working alleviates symptoms 9 for individuals who with. The clientele social work have been diagnosed with serious practitioners usually work with is diverse illnesses, and is characterized by a team- itself. Besides, more diversity arises within oriented approach which refers to each culture that composes the population collective practice on the behalf of the of the State (Ivey, Ivey, & Zalaquett, patient’s needs and wishes. This form of 2010; Gernstein, Heppner, AEgisdottir, quality care, which is used in a variety of Alvin Leung, & Norsworthy, 2009; Sue & Hospice units in the state of Hawaiì, Sue, 2008). There are numerous unique segues into Hospice care. The latter is a personalities and family dynamics within type of palliative care which is offered in the cultures, which may influence the way the (anticipated) last six months of the individuals, families, or groups experience patient’s life, and is mostly focused on death and dying, and grieve for the death caring, and not curing (Saunders & Clark, of a loved one. Additionally, great 2002). As indicated in the Kokua Mau 10 differences may be obvious among organization’s original site, hospice care is individuals, even more than the ones provided on all the islands of Hawaiì. among cultures (Woods & Hollis, 2000). Hospice care helps to alleviate the For example, an older Native Hawaiian stress that is encountered during the dying might believe that people who have lost a process by taking a holistic approach to loved one can connect with each other in treatment. It often serves as an a unique way that no one else can, educational tool to the person and their whereas a teenage member of the same family. Hospice also provides awareness family believes that this is a superstition of the options that are available to the (Kanuha, 2005). dying person. Hospice organizations also According to Leung, Cecilia, Siu- seek to educate the community and health Man, and Mo-yee (2009) a body-mind- care workers (including social workers). spirit approach that they have studied in The word hospice comes from the root clinical social work settings, and which word for hospitality in Latin. In basic was emphasized to bereaved Chinese terms, hospice means to provide women who were following Daoism or hospitality to the dying person and their Buddhism at that time, was incredibly family. This means giving palliative or effective with the research participants. comfort care to the dying and helping Saleh (1997) has used a case study of a their loved ones in many ways. Micronesian client to address barriers Cultural diversity among the while counseling, as well as solutions and population one works with may increase effectiveness of counseling interventions. the challenges of practice in hospice The main approaches, and their (Ponterotto et al., 2010; Gernstein et al., effectiveness, that have been used in the 2009; Sue & Sue, 2008). Some cultures past, and are being used at the present, with the population of Hawaiì are 9 discussed below. As opposed to care with primary goals of addressing cause and cure.

10 Kokua Mau is Hawaii’s hospice and palliative care organization. Additional information at: http://www.kokuamau.org/

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(and health care providers) may be more historically been used within Pacific receptive to palliative and hospice care, cultures such as Samoan, and Tahitian and thus the effectiveness of this type of (Forisha et al., 2005). assistance to the population may vary. For This special Hawaiian approach has example, Samoan populations prefer the been used in the 21 st century for youths, as family to be the care giver for the dying well as prolonged bereavement instances. person and usually do not accept hospice As for the latter instance, it is believed care (Little, 2009), whereas Japanese with hoòponopono that the bereaved culture is more receptive to this type of individual, with the help of the professional assistance (Bell et al., 2009; environment, and in a group process, in Laungani, 2004). order to overcome the loss of a loved one, According to the study by Bell et al. has to go back to level Zero , in which (2009) more Asian Americans have died memories stop being redelivered into the as inpatients, as opposed to the numbers mind. From that level, the person can be of Caucasian Americans. Additionally, functional again, and pass to the both Chinese and Korean dying patients acceptance stage of the loss (Forisha et al. have been depicted as more resistant to 2005; Nishihara, 1978). However simple hospital and hospice care as opposed to the process sounds, there are complexities other cultural groups (Kwon, 2006; Chang when it is applied with different Pacific & Ng, 2002). cultures (Forisha et al., 2005; Hurdle, According to Little (2009) and her 2002). observations with American Samoans, NHPIs, especially Native Hawaiians, palliative care has illustrated increasingly Samoans, and Guamanians, seem to have effectiveness with that population. Last, been more accepting of the approach, as handbooks of counseling with diverse similar beliefs on the wisdom of elderly in populations and multicultural counseling the family system are held (Forisha et al., have provided valid information when 2005; Hurdle, 2002). That being said, the working with NHPIs, as well as Asians process is often practiced by an older and Asian Americans (Ivey et al., 2010; family member and not a social worker. Ponterotto et al., 2010; Gerstein et al., However, there have been social work 2009; Sue & Sue, 2008; McGoldrick, practitioners who have shown interest in Giordano, & Garcia-Preto, 2005; this approach and have committed to Laungani, 2004). receive training from kahuna (Forisha et al., 2005). Hoòponopono Hoòponopono has been an effective Hoòponopono (“to make right”) is a culturally-based approach regarding the process of solving problems and an Native Hawaiians, Samoans, ancient Hawaiian practice of forgiveness. Guamanians, and other Micronesians It was traditionally practiced by kahuna (Forisha et al., 2005; Hurdle, 2002; (traditional healers) to maintain harmony Nishihara, 1978). The o`hana feeling has in the community and within oneself also been described as an effective (Forisha et al., 2005; Hurdle, 2002). With intervention for family therapy (Kanuha, the practice of hoòponopono, the 2005). In addition, Sue and Sue (2008) individual can rediscover his/her true have conducted research that indicates identity after a crisis such as a death. specific culturally-based behaviors Similar processes as this one have concerning counseling with NHPIs.

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Huna, Hakomi Therapy, and Spirituality healing aspects of the latter is that The only way that someone can run a negative emotions, such as anger and life the exact way he/she wants to, is to hate, are always accepted, and not connect with his/her spirit. This is the rejected as in traditional western core belief of Huna (Hartman, 1985). The psychology (Hartman, 1985). teaching and practice of Huna is about In Hakomi therapy it is supported that empowerment and increase of spirituality. the disease is and has to be one with the It has been believed in ancient Hawai`i, cure. The understanding of both will lead and also to the 21 st century, from Native to development and health. Hakomi Hawaiians and other groups, that it can therapy does not condone the absence of free the spirit of the bereaved and attach it spiritual beliefs. The main concept of it is to the wholeness of the experience, in to teach, in a non-judgmental way, the order to make sense out of its parts “knowing of God” and spirituality (Kanuha, 2005; Hurdle, 2002; Hartman, (Hartman, 1985). 1985). This approach has, for years, been Kahuna , who have performed Huna , performed by a family member or believe that, for someone to better practitioner who has gained knowledge understand him/herself (needs, hopes, and expertise through training with a fears, etc.), he/she has to understand God kahuna . It has been effective to bereaved first (Hartman, 1985). In the Huna beliefs, and dying individuals among NHPIs, as God is a whole entity, which includes all Chamorro people and Micronesians the individuals, whether they are dead or (Salef, 1997). alive, and thus God is one of the main Nowadays, Hakomi therapy can be principles of Hakomi therapy 11 . Huna taught to practitioners either as full focuses on two parts of the inner studies, or as a certificate program. Both experiences: the aumakua 12 (high self, options are available through the Hakomi super conscious), and unihipili (low self, Institute 13 . Training in Hakomi therapy subconscious) (Hartman, 1985). Those may last approximately 360 hours over two can otherwise be introduced as the two years. By the end of the training mind and the spirit (Hurdle, 2002). practitioners are identified as Certified While grieving to the loss of a beloved Hakomi Therapists (CHT) or Certified one, someone cannot experience Hakomi Practitioners (CHP). wholeness (the connection with his/her spirit, the connection and understanding Individual and group psychotherapy . of God) due to rejection of a part of Psychotherapies come in different existence or non-existence (death in this forms, such as counseling, and cognitive case). Acceptance of the death experience behavioral therapy (CBT). Both are the and the grieving process are significant in type of therapy commonly used by clinical this way in Hakomi therapy. One of the practitioners in the State of Hawai`i, with

11 Hakomi therapy is explained later in the section, 13 “Founded in 1981 by Ron Kurtz and a core but referred to currently due to its attachment to group of trainers, the Hakomi Institute is the Huna beliefs. original and most extensive organization providing information and training in Hakomi Experiential 12 This word is also used, as mentioned in chapter Psychotherapy.” More information are available at: 1, for the family’s totemic representation, their http://www.hakomiinstitute.com/ “god”.

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effective results and outcomes in the and cultural awareness. The same sessions (Doyle, 2011; Sue & Sue, 2008; principles are highlighted for the second Yalom & Leszcz, 2005; Corey, 1995). and third areas of focus, which are the However, different techniques, and skills culture of the client, and the multiplicity of any type of psychotherapy should be of variables comprising an individual’s adjusted to the needs and characteristics identity/personality (Pon-terotto et al., of each culture that it is used for (Gerstein 2010; Jordan & Neimeyer, 2003). et al., 2009; Saleh, 1997). For example in According to Saleh (1997) counseling the Korean culture, minors are usually not techniques and skills have been allowed to attend therapy even if it has to increasingly effective with Micronesian do with prolonged grief (Laungani, 2004). clients. As well, Wada & Park (2009), in On the contrary, pastoral counseling 14 is order to improve clinical (individual and preferred by this population (Kwon, group) practice with Buddhists who are 2006). grieving, explored the integration of Buddhist psychology into grief counseling. Grief Counseling By the results of their study it is shown Hawai`i has been defined so far as a that Asian clients were more receptive to “gathering place” of diverse cultures and this combined approach, regardless their religious orientations. This diversity has religious orientation. To that extent, this indicated different practices, customs, finding seems the same for any clients beliefs, and values regarding death from a specific faith perspective, as long as experiences, and bereavement (Ponterotto it is done sensitively. et al., 2010; Sue & Sue, 2008). Micronesians in general tend to Grief counseling and more specifically emphasize their family systems, and few multicultural counseling for grief have would go individually in therapy. This is been used by clinical practitioners (not probably the major reason why necessarily social workers), as a type of Micronesian clients are few in number, psychotherapy to help clients go through and mostly rely on the deity. Similar the dying process, and/or help bereaved values are held by some Samoan families individuals and families to overcome grief in the State of Hawaii, whereas Native or prolonged grief (Gilbert, 2010; Hawaiians, and Samoans tend to prefer a Gernstein et al., 2009; Gamino, Sewell, family counseling process which is led by Hogan, & Mason, 2009; Glazer & a “chief” in their family system, who is Marcum, 2003; Corey, 1995). usually one of the elder and wiser, Multicultural grief counseling according to Hawaiian and Samoan includes three areas of focus which can be beliefs, respectively. For the same reason, effective within the population of Hawaii, ho`oponopono and hakomi therapy have due to its composition. The first area been successful in the past with these refers to the culture of the populations and other Pacific Islander counselor/social worker, which groups. underscores the necessity for competence Family Therapy Native Hawaiians and Other Pacific 14 Pastoral counseling is a type of counseling in which priest, ministers, or other persons receive Islanders, in general are family and group education on religion, spirituality, and counseling oriented cultures (Ponterotto et al., 2010). techniques in order to provide clinical services Common beliefs and sets of values can be from a spiritual and religious perspective.

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found regarding the sense, meaning, and values and skills are close to a perfect understanding of family bonds. Many match with hospice and palliative care people, including Hawaiians and/or programs, which are designed to treat the people who live in Hawai`i, show whole person in an interdisciplinary preference for practices performed by a manner to enhance quality of life during family member (preferably an elder, who challenging times (Sue & Sue, 2008; is the wisest in the system), rather than a Kubler – Ross & Kessler, 2005; Callahan, social work practitioner (Hurdle, 2002; 1999; Kubler – Ross, 1979). Saleh, 1997). However, in such cases, that Social workers promote client self- social worker might want to take more of determination and are culturally aware a facilitative role, or at least make it clear and thus more appropriate for care. They that he/she recognizes the elder as a should be qualified in evaluating the resource in the system. These cultures are strengths of individuals and families, and receptive to family interventions understand that good medical care (Ponterotto et al., 2010). requires that the wishes and needs of the Asians and Asian Americans are also individuals being served are respected receptive to family and group (Kubler – Ross, 1979). When cure is no interventions, but from a different longer possible, a host of psychological, perspective. Asians and Asian Americans physical, and spiritual stressors arise promote hierarchical relationships, that social workers are specifically trained different from Pacific Islanders (Sue & to assist the individual and family to cope Sue, 2008). It is essential for the family or and manage. group to follow these hierarchies, as long Coping with loss and the ensuing grief as the well-being of the system results process is another area in which social from it as well (Sue & Sue, 2008; Chang & workers are well versed. Dealing with the Ng, 2002; Agbayani-Siewert, 1994). For intense emotions associated with grief can example, when social workers work with be overwhelming without the proper Filipinos or Filipino Americans it is support and information. Social workers important to avoid directive and in this field are specially trained to help confrontational styles, as well as to treat facilitate grief and help people avoid both genders equally in a family therapy obstacles that can lead to more (Agbayani-Siewert, 1994). Chinese complicated reactions like depression families may be more reluctant than other (Kamana`opono, 1999). It becomes of Asian cultures to accept family therapy great importance for the social worker to when a death occurs (Chang & Ng, 2002). be aware of the culture he/she is working with, in order to accomplish goals and Potential Challengess for Social Work Practice objectives that are adjusted and well– with the Population of Hawaii. matched to the beliefs and values of the The purpose of the profession of social population (Ponterotto et al., 2010; Sue & work is to help the client enhance or Sue, 2008). restore his/ her capacity for optimal Cultural competence is a determinate psychological, emotional, spiritual, social factor of the social worker’s effectiveness and physical health. Social workers and of the effectiveness of the counseling provide primary and secondary services in process (Ponterotto et al., 2010; Gerstein hospitals and hospices, and participate on et al., 2009; Sue & Sue, 2008), and of any palliative care teams. Their professional level of social work practice (micro,

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mezzo, and macro) in general. Having the treated equally on respect of both. Also, knowledge and the awareness of the way especially in the Korean culture, minors Hawaiians perceive death, dying and are meant to follow their parents’ desires bereavement might help the practitioner, and sacrifice for the family’s best interest. by integrating that knowledge into While exploration may be appropriate, practice, to fully understand the grieving opposition to such a belief would most person’s mentality and to that extent be likely end up ruining the interpersonal able to contribute in a more productive relationship with the parents, as well as and effective manner via counseling, violating social work ethics. facilitation or support. Experiencing the loss of a loved one is, Macro Level of Social Work Practice and its if not the most challenging, one of the Effectiveness major crises in life. Individuals and/or Death, dying, and bereavement are families who go through that process, experiences that are addressed not only might be completely disorganized in their from a direct practice perspective, but also minds at that moment and thus from a community based one (Wolfer & dysfunctional for any purpose (Kubler – Runnion, 2008). Macro practice mainly Ross & Kessler, 2005). Including refers to and focuses on larger systems and themselves in grief counseling, for social change. Systems theory is a instance, has specific purposes, and one of determinant component of macro them is to educate the social worker, or in practice, while the latter indicates policy general the counselor, about cultural analysis, policy advocacy, social planning, elements. Those elements are most likely community organizing, community to provide additional information to the development, and other types of practitioner, in order to understand the interventions on this level (Burghardt, meaning the bereaved gives to the loss and 2010; Netting, Kettner, & McMurtry, what the rationale of that meaning is. 2008). Native Hawaiians, Samoans, Chamorro, Social needs and problems that are and other Pacific Islanders, for example, addressed through death, dying, and pay critical attention to spirituality and bereavement processes in Hawaii, as well religion, and are also somewhat as other communities, are subjects of and superstitious (Ushiroda, 2008). Having opportunities for change, for the well- knowledge about these characteristics of being of the parts of the community and the culture can help the practitioner to be the community as a whole. As referred to more effective in therapy when earlier, a few of the essential social conducting social work on a micro level. problems that the bereaved population of According to Hepworth et al. (2010) Hawaii is dealing with are acculturation creating awareness about the population and enculturation, risks of prolonged grief, one works with is also a method of and, to an extent, loss of cultural identity enhancing the positive outcomes of the (Gernstein et al., 2009; Sue & Sue, 2008). direct social work practice one conducts. Social problems such as these may affect Within the Asian cultures, for instance, it and be influenced by death experiences becomes essential that the social worker is and bereavement. knowledgeable about the hierarchical Enculturation among the population structure within the family system. When of Hawaii is conceived as the process of in family therapy, the spouses need to be majority groups who willingly acquire

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customs, beliefs, and values from the those services is mainly performed within indigenous culture, Native Hawaiian, so the social services and social work they can better fit in the Hawaiian departments of the health settings. community. On the other hand, Hospices comprise a tremendous relief acculturation mostly refers to minority and support for dying people and their groups in the state, as Native Hawaiians, families and friends. Macro practice is Samoans, Guamanians, African demonstrated within these settings for Americans, etc. With acculturation, social planning, implementation, and individuals are imposed with cultural evaluation of the services and the specific beliefs and values from the dominant programs that are offered (Burghardt, group of residents. Often enough, people 2009; Evan, 2009). tend to lose their cultural identity due to Lantern Floating Hawaii is a this process (Sue & Sue, 2008). Needs that ceremony held each year on Oàhu on arise from such problems and/or risks Memorial Day. Lantern Floating brings may be addressed from three different together, every year, more than 40,000 perspectives: state , national , and residents and guests of the islands who international . cast afloat lanterns in remembrance of loved ones, or as a symbolic prayer for a State, National, and International Levels of harmonious future. The ceremony is led Macro Practice by the spiritual head of Shinnyo-en 15 . As A great deal of rallying and advocacy stated by one of the residents during the has taken place, since the 1800s in 2010 ceremony “Nobody dies, because, if Hawaiì by residents from diverse there is a connection of love between the ethnicities and backgrounds. Among the people who are here and the people who most important causes for Native passed on, the life continues” (personal Hawaiians are legislation that has communication, May 31, 2010). With this addressed respect for the bones of the ceremony, the people of Hawaiì deceased, the death process, and a reminisce and honor those who have communal respectful behavior toward the passed, friends and family, as a united death of the indigenous people, as well as community. Even though this ritual toward bereaved individuals, families, and comes from Buddhism, this has never groups within the community. been an obstacle for people from different Local communities offer a handful of spiritual orientations to join, and this programs and services both for people becomes one of the strengths the who are dying and for people who are population of Hawaiì demonstrate. grieving. Quality of life is the dominant NASW standards for palliative and focus of the existent programs, which are end-of-life care (2004) state: delivered through governmental, non- The social worker shall advocate for the governmental, and voluntary organi- needs, decisions, and rights of clients in zations and agencies (i.e. child welfare and family services, health services, senior 15 centers, substance abuse programs). “Shinnyo-en was founded by the accomplished Hospitals and nursing homes make a Buddhist master Shinjo and continues to thrive under the spiritual guidance of his daughter and worthwhile effort with end-of-life services, spiritual heir, Her Holiness Keishu Shinso.” See to promote quality services to needed additional information at: families and individuals. The planning of http://www.lanternfloatinghawaii.com/shinnyoe n.html

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palliative and end of life care. The social The Effectiveness of Policies, Organizations, worker shall engage in social and and Programs political action that seeks to ensure that According to Mokuau et al. (2008) people have equal access to resources to NHPIs have been identified by the 2000 meet their bio-psychosocial needs in Census as a distinct and unique minority palliative and end of life care. (p. 4) group or race, which holds its own history Policy advocacy and policy practice in and background. This identification had a general have both been performed at major effect on the population of Hawaii. length on the behalf of the population, in Social work practice with the population order to improve and empower the quality of the State has not been highly effective, of services and programs that are in terms of cultural expertise, due to lack delivered to those who experience death, of information among different cultural and those who grieve for the loss. and religious groups. To that extent, death NASW (2001), as well as the and dying attitudes, and coping and International Federation of Social bereavement mechanisms and behaviors, Workers (IFSW) (2009) have essentially are as yet unidentified for each culture. achieved culturally based philosophies of In their literature review, Mokuau et the social work profession. Each cultural al. (2008) focused on publications that group is unique and holds independent referred to social work practice and customs, beliefs, and values that have to NHPIs. The review was conducted be respected and sensitively addressed by between 1994 and 2004, when only 32 social work practitioners (Gernstein et al., articles were found in 23 different 2010). Cultural awareness has become of journals. The results have shown that critical importance in the past few limited information has been published decades, especially since the 1990s (Sue & regarding the NHPIs, and that much Sue, 2008). According to the International information published is combined with Association of Schools of Social Work the population of Asians and Asian (IASSW) (2009) social work education, Americans, regardless their residence, regardless of concentration, has to be which hinders evidence-based practice. filled with culturally sensitive information. The identification of the populations These standards from national and which inhabit Hawaii has been a international associations are landmarks cornerstone to the development of policy for social work practice in Hawai`i as practice and innovative research regarding well. The needs to conserve one’s cultural different cultures, death, dying, and identity and avoid unintended bereavement. As long as social work acculturation are the focus of such research has been retrieving information standards. Doing so, a community on different cultures, and evidence-based consisting of numerous different cultures practice can be applied, new programs will then become a multicultural and services can be culturally-based and community, and not a community with more effective to the diverse population different cultural minority groups they address. According to data from the (Ponterotto et al., 2010). In these terms, KP (2009) only 2,735 people are using within a multicultural community, equity hospice services in Hawai`i. An and social justice are essential assumption to this number may, as determinants for its existence, mentioned by Forisha et al. (2005), be the development, and maintenance. limited expertise of the staff regarding the

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diversity and multi-ethnicity of the Current Findings clientele. Other assumptions may include Limited research has been conducted different perceptions of different ethnic to today, regarding death experience, and families regarding hospice care, or the death, dying, and bereavement attitudes possibility of sufficient resources within and behaviors of the population of Hawaii one’s own family system. (Gilbert, 2010; Mokuau et al., 2005; Hurdle, 2002). Mokuau et al. (2005) have Social Work Research based their literature review on 32 articles The IFSW (2011) states that: published within a ten year time frame. Social work bases its methodology on a That number equals to 0.64% of the systematic body of evidence-based articles published in the specific journals knowledge derived from research and during that period (Mokuau et al., 205). practice evaluation, including local and A great number of the articles referring indigenous knowledge specific to its to the State of Hawai`i are focused on context. It recognizes the complexity of Asians alone and Asian Americans interactions between human beings and (Breen, 2010; Bell et al., 2009; Wada & their environment, and the capacity of Park, 2009; Chan et al., 2005; Kanuha, people both to be affected by and to alter 2005; Chang & Ng, 2002; Hurdle, 2002; the multiple influences upon them Agbayani-Siewert, 1994; Hartman, 1985; including bio-psychosocial factors. (p.1) Nishihara, 1978). According to Bell et al. Social Work practice itself would not be (2009) and the showings of the Honolulu- effective if the theories, skills, Asian Aging Study they have conducted, competencies and knowledge were not Asian Americans tend to follow their tuned-in to the constant changes of the Asian cultural background to determine world and the cultures that inhabit this their death attitudes and behaviors. world (D’Cruz & Jones, 2004). The profession's main mission, as stated by the Dearth of Data NASW, is the well-being of the systems The population of Hawai`i has faced (individuals, families, groups, organi- acculturation to an extended level, and zations, communities) that social workers thus lots of work and research is still serve. In order to attain the state of well- required, in order to promote and improve being, one needs to be aware of the needs culturally-based and grounded inter- of the population he/she serves, ventions at all levels. The current data depending on the geographic, age, from social work research regarding historical, cultural, educational, etc. death, dying, and bereavement among this differences and changes through time. population lacks significant references, Social work research is the most whereas the social needs of the population effective approach for social workers to increase and become more complex as the become aware in their field, gain environment and the interactions between evidenced-based knowledge, and follow the systems and the environment become up with the changes and new needs of multifold (Gernstein et al., 2009). their clients. This type of research aims to There is a dearth of information when promote knowledge and increase skills working with dying and grieving Native and competence level of the practitioners Hawaiians, Samoans, Chamorro people, (Grinnel & Unrau, 2010; D’Cruz & Jones, and other Pacific Islanders. This gap 2004). increases the limited effectiveness of social

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work practice on all levels, as well as the to the ethical practice of Social Work. It is expertise of the social work practitioners. important for practitioners to be sensitive This should be an area of high priority for to those differences and make decisions social work practitioners. which are culturally sensitive. As mentioned by Sue and Sue (2008), social LEGAL AND ETHICAL ISSUES ASSOCIATED workers should first identify the areas of WITH THE POPULATION OF HAWAI Ì ethical dilemmas with clients from different cultures, and then proceed to State and federal laws have to be interventions. followed by every individual. Sometimes Significant attention has been given individuals and/or families from various lately to ethical conflicts that arise in ethnic and cultural backgrounds may hold multicultural settings (Muller & opposite ideas on what should be done. In Desmond, 1992). Especially in hospital situations like that, the family’s settings when someone dies, differing preferences are illegal in the State of cultural and value-based backgrounds of Hawaiì. For example, Samoans believe the individual/family and the that the burial of the deceased family practitioners may increase the complexity member in their own property will keep of the situation and will affect the given the family together based on constant procedures. According to Muller and communication. According to state laws, Desmond (1992), a variety of ethical this is an illegal action and people from dilemmas and issues arose after the death that race have to follow different practices. of a Chinese woman in a hospital. Those Of course these are instances that cannot dilemmas included the withdrawing of the radically be changed by social workers, fact of death from some family members, although certain services and/or programs the role of the family in making medical for Samoans could be planned and decisions, and the impact of such developed. For example a cemetery for dilemmas on the family system. The Samoan family members could be created authors examined all the effects those and memorial programs could be offered issues had on the family system, and by the community. highlighted the need for more research As discussed earlier in the paper, and expertise in such multicultural certain lawsuits are influencing the contexts. population of Hawaiì, and specifically Social Work practice has made a Native Hawaiians. House Bills and Acts significant contribution to experiences (e.g. Act 001) which relate to the bones of such as death, dying, and bereavement the ancestors and their maintenance of (Evan, 2009). However, cultural their own land, as opposed to transferring competence of the practitioners is still a the remains to different locations, show subject for development. Lo (2009) effectiveness till today and are addressing underscores how ethical dilemmas can be legal issues that may arise. On the other resolved when the practitioner becomes hand, ethical issues which are not guided aware of the different cultural groups of by laws but by cultural ramifications and the community he/she is working for/in. subjectivity are harder to resolve and to It is also highlighted that ethical dilemmas that extent make judgments critical. do not necessarily arise just from cultural Respect for different customs, beliefs, differences, which may lead to more and values is an essential issue that relates intense complexity of the ethical issues.

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IFSW & NASW Codes of Ethics nature of social diversity…with respect to Both IFSW and NASW state specific race, ethnicity, national origin, color, …, principles and ethical codes, which have religion, immigration status…” to be followed by social work Both IFSW and NASW Codes of practitioners. Those codes of ethics refer Ethics refer to areas that are sensitive for to a sensitive practice and, for the the population of Hawai`i, and more purposes of this paper, culturally-based specifically the bereaved residents. Even interventions, which will promote and though the accepted values and codes of maintain the well-being of the people who ethics do serve the population, better are receiving services. understanding of the diversity in the IFSW (2009) states, at the preface of specific community, Hawaii, is needed. the statement of principles, that: “Ethical Knowledge, not only of the different awareness is a fundamental part of the individual cultures but of their existence professional practice of social workers. as a whole and their interactions is still Their ability and commitment to act needed and most likely in need of ethically is an essential aspect of the improvement by social work practitioners. quality of the service offered to those who use social work services.” Cultural PART III: CONCLUSIONS sensitivity and awareness are major parts of the principles. According to the IFSW, IMPLEMENTATIONS IN SOCIAL WORK social workers should treat every client PRACTICE AND system based on the principles of human IMPLICATIONS FOR SOCIAL AGENCIES rights and dignity, social justice, and professional conduct. In all these three Social work practice on issues principles, social workers ought to provide associated with death, dying, and services based on the interest of the bereavement may be found in numerous clientele, their cultural and ethical settings, as these are universal concepts of background, and their current beliefs, and life. Hospitals, hospices, nursing homes, values. “Social workers should recognize geriatric settlement houses, and others are and respect the ethnic and cultural settings which may frequently include diversity of the societies in which they grief-related social work practice. In practice, taking account of individual, addition, policy practice in agencies and family, group and community organizations (e.g. Non Governmental differences.” ( IFSW, 2009). Organizations 16 [NGOs]), Child “Social Workers are sensitive to Protective Services (CPS), Adult cultural and ethnic diversity and strive to Protective Services (APS), or community end discrimination, oppression, poverty, programs may as well include social work and other forms of social injustice.” with dying people or grieving individuals (NASW, 2001). NASW sets up standards and systems. Social workers, as other and expected competences for social work practitioners, will most likely encounter practitioners, which will promote and such issues in their work with clients, at increase social justice within the any level of practice (micro, mezzo, communities. According to the 2008 and/or macro) (Calahan, 1999). revised Code of Ethics, paragraph 1.05 (c) states: “Social Workers should obtain education and seek to understand the 16 More commonly known as nonprofits in the United States.

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practice, for it will eliminate micro-insults, micro-aggression and in general unintended behaviors and practices from the practitioner’s perspective. Second, practitioners should be aware of the cultures of their clients. Even if awareness has not come through education or personal enactment, having clients teaching the social worker may be productive and in the long run effective.

“Graveyard,” Christi Sava, stock.xchng All the cultures examined in this paper are centered on either a collectivistic or an Paragraph 1.05, section (a), in the individualistic perspective. Native Hawaii- NASW Code of Ethics refers to the ans, Samoans, Chukeese, Marshallese, necessity for understanding cultures and Fijians, and Guamanians are all cultures the importance of strengths perspectives of a collectivistic preference. Hence, there when working with diverse individuals is an initial preference for someone who is and/or systems. (NASW, 2001, p.7). dying to be taken care of a family Knowledge of information such as is member, rather than a nurse, while at the provided through this theoretical same time, grief is more welcome indoors, approach of correlations and crosstabs among relatives, rather than in therapy. about death, dying, bereavement, culture, Hierarchical relationships have been and religion may be critically useful for critical in many cultures that have been social workers. Such data do not only examined in this paper. Filipinos, as well reveal the strengths of each culture one is as Chinese young adults, usually make working with, in addition they provide full end-of-life decisions for the parents, understanding of a different worldview whereas Koreans follow different patterns which may be determinant in the helping when it comes to such decisions. process and helping relationship. Traditionally, in the latter culture, even if Cultural awareness regarding the the patient is the father, despite the concerns, practices, and behaviors of one’s struggles, he will make the decisions. clientele may lead to effective Finally, social workers should be implementation of theories and prone to understanding the interactions approaches (Hepworth et al., 2010; and differences of the diverse cultures, Dinitto & McNeece, 1997; Hancock, especially between them and the clients 1997). Awareness of culture has three (Hull & Kirst-Ashman, 2004). Being different components. aware of the cultures that merge into the First, social workers 17 should be aware helping relationship is not enough. The of their own culture, including prejudices, products of such a cultural relationship, typical behaviors, and certain spiritual and though, may add significantly to the religious rituals attached to the culture process and to the effectiveness of the (Derezotes, 2006). Self-awareness is a practice. critical element of productive and effective “Figuring out how an individual client thinks and functions is fascinating.” (Hull 17 This information and these conclusions may & Kirst-Ashman, 2004, p.19). Social work apply to more disciplines. However, for brevity I practice with bereaved individuals does will be referring to social workers only.

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not only consist of comfort practices, or practice (Jansson, 2010). According to adjustment tendencies. Change is a radical Hull and Kirst-Ashman (2004) the ability component of this practice and critical in to apply knowledge which concerns social work with bereaved systems and/or different cultures is an essential part of dying people. “What is left ungrieved cultural competence. Such applications on remains stored in our body, heart, and the macro level of social work practice soul. It can come out each time we may increase the sustainability of human experience loss anew.” (Kubler-Ross & services in the State of Hawaii. Also, as Kessler, 2005, p. 73). Prolonged grief implied by Bell et al. (2009), the same situations/issues may increase the need applications may promote new trends and for the practitioner to focus on cultural tendencies to the populations in need, as strengths, which will allow him/her to opposed to lack of knowledge and/or trust fully conceptualize the reasons why the of the services provided in one’s com- grief is prolonged, as it may originate from munity. different causes rather than clinical ones. Sue and Sue (2008) have suggested For example, Filipino families are that ignorance is a determinant factor for expected to prolong their grief and extend micro insults and micro aggression in the their emotions for more time than is usual society. Social services are provided by in the Western cultures. If this is not the certain individuals/workers who work at case, then disrespect is shown to the those services. These practitioners will person who passed away. promote the wrong idea to the service Hull and Kirst-Ashman (2004) have seekers, and discourage them on seeking stated: “The individual is right in front of the services again, unless they you. The other systems with which the (practitioners) are aware of the individual client is involved are much population, its needs, challenges, more abstract. Their interactions and strengths, and weaknesses. All these may effects may seem vague and distant. be included in one’s culture. Because of the complexity of the outside systems, pinpointing targets of change ETHICAL CHALLENGES AND often seems more difficult” (p.19). RESOLUTIONS Different cultural perspectives regarding death, dying, and bereavement As discussed earlier in the paper, attitudes and behaviors, as well as numerous ethical challenges, which are traditions and customs, can lead to rooted in cultural characteristics, may productive program evaluations and arise through social work practice. assessments. What are the existing NHPIs, or at least a majority of these programs and services that are provided to cultures, and specifically Native the population of Hawaii? What are the Hawaiians, Samoans, Chamorro, and theories and approaches on a macro level Chukeese tend to have a chief member in that are applied in this State? These the family. That member is the person elements may be examined through a who will make the end-of-life decisions new, culturally-based scope, and thus when the time is right, and nobody else. provide feedback which will promote “When my grandfather died, we were still needed changes based on the new needs of in Guam, and we had to wait 11 hours for the population, and additionally improve the doctor to tell us, because he was the outcomes of community-based waiting for the ‘chief’ of my extended

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family to be told first” (personal its environment (Person-in-Environment communication, April 2, 2011). ‘PIE’). Social workers work with the Ethical challenges and dilemmas can person, the environment, and the be experienced in many different ways, interactions between the person and the depending on the cultural awareness of environment. The social worker in the last the social worker. Value conflicts can arise case can be seen as a mediator, for especially when a social worker is example, between the physician and the providing services to clients whose client. Both need to understand why the religious or cultural beliefs support other party is making the decisions that different behaviors than the social are made. Additionally, the client system worker’s. In this case, it is the social needs to understand what the best choice worker’s responsibility to figure a safe is at that moment. channel of communication and practice This paper has provided in-depth which will promote the client’s well-being information and syntheses of religious and (NASW,2007; Hugman, 2005; Dinitto & cultural information. With this provision, McNeece, 1997; Gambrill & Pruger, 1997; social work practitioners may equip Wells & Masch, 1986). themselves somewhat better for future Working at a hospital or a hospice practices. Ethical challenges and/or with clients from many different cultural ethical dilemmas have no specific and religious values, and beliefs increases resolutions. Some choices, though, are the obligations for awareness on these better than others, and some choices may issues, and also the need to be mindful of be unethical. However, though being any possible ethical dilemmas, and/or culturally aware and/or applying conflicts. For example, when a Samoan culturally-based practices, such decisions child needed an operation in a hospital may become easier to make, and thus setting, the mother was not willing to sign more acceptable to both the social worker the paperwork for the procedure to take and the client. place, regardless the severity of the situation. Although under Hawaii law FUTURE TRENDS FOR SOCIAL WORK she had to give her consent, she insisted RESEARCH on waiting for the chief of the family to come in and do the signatures. Culturally Research in effective interventions to she was not allowed to do what the meet the needs of different populations is physician was asking her to do (personal necessary. Furthermore, not all bereaved communication, March 29, 2011). In this people, even from the same culture, ethical challenge, it was critical for all the express themselves in the same ways or parties to be culturally sensitive. share the same experiences in managing Understanding of the situation, and the grief. Research needs to include bereaved client’s willingness, as opposed to persons from a broader spectrum of the aggressive and non friendly behaviors and population of Hawaii. Due to the diversity communications, can lead to more of the population, “bereavement studies successful practice. This example may be should systematically test for cross- explored through the ecosystems cultural and ethnic comparisons” (Lund & perspective. Social workers do not only Caserta, 1998, p.295). More hetero- work with the client/client system. They geneous samples need to be included in also do not only work with the system in the studies, with sufficient numbers of

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Hispanic, Native Americans, African critical areas for implementing change Americans, and other Pacific Islanders, in palliative and end-of-life care (p.14). such as Fijians or people from the In order to gain knowledge of and Mariana Islands. It is important to expertise in the areas mentioned above, compare cultural similarities and social workers need to follow NASW’s differences to more fully understand the continuing education philosophy. NASW process of grieving in the community, and views continuing education as “an in organizational settings. To that extent, essential activity for ensuring quality sophisticated knowledge and awareness of social work services for clients” (NASW, such similarities and differences can lead 2003, p.7). Furthermore, NASW to an emphasis on which interventions or encourages and essentially supports social work strategies are more effective cultural competence in social work for which culture. practice (NASW, 2007; 2001). Another challenge for future social Hawaii is a State that is constantly work research is to improve the undergoing demographic changes, and understanding of the impact of religious thus community changes. Such transitions orientation in one’s culture, and, (e.g. new languages, new customs, furthermore, increase the knowledge of increased acculturation processes, and how religious beliefs and practices can be elimination of community participation distinguished from cultural ones, or how unless in same-cultural groups) necessitate those practices can be considered as culturally-based and grounded inter- subcultures. Moreover, the profession of ventions when working with dying social work may be challenged to name individuals, bereaved family systems, specific social work interventions for bereaved communities and neighbor- death and bereavement, not only to hoods. The decision to become a social specific cultures, but specific to worker is a decision to commit to those culture/religion crosstabs (i.e. Asian changes and challenges, and a Agnostic vs. Asian Buddhist). commitment to advocate for the well- being of the ever-changing systems; no FINAL COMMENTS matter how long the “living” state of the client/client system will last. Social As stated by NASW (2004) in the workers should be responsible for quality NASW Standards for Social Work services and quality interventions which Practice in Palliative and End-of-Life embrace the diversity of the populations Care: with which they are working. Social workers have unique, in-depth knowledge of and expertise in working REFERENCES with ethnic, cultural, and economic diversity; family and support networks; Agbayani-Siewert, P. (1994). Filipino multidimensional symptom manage- American culture and family: guidelines for ment; bereavement; trauma and practitioners. Families in Society , 75(7), 429- disaster relief; interdisciplinary 438. practice; interventions across the life Becker, E. (1973). The Denial of Death. New cycle; and systems interventions that York: Simon & Schuster. address the fragmentation, gaps, and insufficiency in health care. These are

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ACKNOWLEDGEMENTS

Many components contributed for the completion of this professional paper, and those should be acknowledged. To start with, I would like to express my deepest wishes and a warm thank you to my academic advisor for this paper, Dr. Mary Sheridan. Even though she was not physically with me, she made her presence perceivable through her support and essential input to the completion of this product. I want to thank her for her unique guidance to this product. A warm thank you and deep appreciations to the faculty of the School of Social Work, at the Hawai`i Pacific University (HPU), for they have taught me well and efficiently to be able to fulfill this requirement. Special thanks to Dr. Loraine Marais, Dr. Pattie Nishimoto, and Mrs. Margo Bare for their support and constant consultation through my “journey” at the school. Special thanks to the State Scholarship “Funeral lights,” rooter, stock.xchng Foundation of Greece (IKY), for I have received support and financial awards for the completion of the MSW. Additionally, I want to thank my parents, Nikos and Eleni. Without them, without their support in any kind, and without their love, this product would not have come to paper, and this program would not have been completed. Last but not least, I want to show my gratitude to my supervisor and close friend, Dr. Vassilios Mpountalis, who has been a supportive source in my academic and professional life, since 2004, and to all of my friends and informal supportive systems, for they stood by me during all this time.

A 2010 MSW graduate of Hawaii Pacific University and a Greek national, Notis Pentaris divides his time between Athens and London, working with migrants and studying in a doctoral program.

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