Psychotherapy Volume 22/Summer 1985/Number 2 S

FAMILY THERAPY FOR ASIAN AMERICANS: A STRATEGIC-

STRUCTURAL FRAMEWORK

SUNG C. KIM
National Asian American Psychology Training Center, San Francisco

A strategic-structural family therapy direct) communication patterns and style, asym-

This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
This document is copyrighted by the American Psychological Association or one of its allied publishers.

framework is proposed as a viable model metrical interpersonal relationships, expectations

for working with Asian American families. regarding concrete, action-oriented therapeutic
outcomes. The therapeutic approach which focuses
A Western-based conceptual model/ on external stress (vs. internal conflicts), empha-
framework is presented that represents a sizes direct problem-solving techniques, suggests
good cultural fit. Also examined is the active problem management (vs. process-oriented
basis of "cultural resistances" from the discussion), and offers external resolution (vs.
perspective of Asian cultural values, family internal resolution) can be more effective with
Asian American families.
structure, and communication patterns.
The strategic-structural orientation is particularly
The framework is intended to identify useful in addressing the problem of underutilization
therapeutic elements that are compatible of mental health services by Asian Americans
with Asian American world views, and (Sue & McKinney, 1975; Wong, 1981). Research
apply them in modified forms more findings indicate that Asian Americans tend to
acceptable to Asian Americans. drop out after initial therapeutic contact, terminate
prematurely, and seek psychotherapy only at the
point of acute breakdown and crisis. Such findings
Most traditional psychotherapeutic approaches have been erroneously interpreted to mean that
do not appear to meet the needs of Asian Americans Asian Americans do not need mental health services
and their families. Their needs stem from well- or that their problems are not serious enough to
ingrained cultural values and beliefs and the effects warrant therapeutic considerations. Quite to the
of immigration which form an essential basis of contrary, an alternative interpretation asserts that
their reality. For example, traditional Western low service utilization exists because of cultural
psychotherapeutic approaches predicated on the barriers, lack of responsiveness on the part of the
assumptions of horizontal relationship, indivi- traditional psychotherapeutic approaches with re-
duation, independence, self-disclosure, and change gard to the unique cultural values and needs of
may go counter to the Asian American values of Asian Americans.
vertical relationship, interdependence, self-control, Wong (1981) noted that the term "Asian and
and acceptance. Pacific American" covers over 32 distinct
An integrated family therapy orientation drawn subgroups and therefore a wide diversity of cultural
from two of the systems approaches (Madanes & norms and characteristics (both between and within
Haley, 1977) is proposed as a better fitting model groups). Thus, the adoption of the "Asian Amer-
for working with Asian American families. These ican family" as the current frame of reference is
are the strategic (Haley, 1963) and structural a heuristic one. The frame of reference is useful
(Minuchin, 1974) therapies. The framework is since a large segment of this population is made
conceptually more compatible with traditional up of immigrants or refugees, whose predominant
Asian world views, family structure, values, (in- value system would be traditional. A total of 98%
of all Indochinese, 90% of all Koreans, 70% of
Requests for reprints should be sent to Sung C. Kim, National all Filipinos, and 60% of all Chinese residents of
Asian American Psychology Training Center, 3626 Balboa the United States are recent immigrants (Wong,
Street, San Francisco, CA 94121. 1981).

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 Family Therapy for Asian Americans

The theoretical basis of the strategic and struc- of a family directly affects the power distribution
tural approaches may be universal, but their tech- in the family. Because of the relatively horizontal
niques are culturally based/biased; therefore, the relationship among family members in the Western
range of its application needs to be broad. For culture, the power in the family can be concep-
this reason, the term "strategic" is used rather tualized as being fairly evenly distributed across
broadly, without strictly adhering to the concepts family members in this culture. However, the
and practices employed by those who developed vertical, hierarchical structure of the Asian Amer-
the strategic and structural family therapy ap- ican family places the father in a position of un-
proaches, as reviewed by Stanton (1981). The disputable leadership and unquestionable authority
term is used in the sense that the therapist initiates and power, with others in subordinate positions.
what happens during treatment and designs a par- Understanding the power structure of Asian
ticular approach for each problem (Haley, 1973). American families is further complicated in that
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

The term "structural" refers to the notion that it is a dynamic process. For example, it is generally
This document is copyrighted by the American Psychological Association or one of its allied publishers.

any therapeutic intervention made by any therapist acknowledged that a wife is subordinate to her
necessarily includes a structural component and husband. A wife is almost an "unperson" until
that a structural aspect of treatment applies to she produces a son, and she does not typically
therapies of all persuasions (Stanton, 1980). The acquire power until she becomes a mother or a
term "family therapy" is also used broadly to mother-in-law. This observation of the subordinate
mean that an individual is a part of the family position of the wife is only partially valid, since
system and as such exists and can be best under- it depicts reality on the public level. An Asian
stood and helped within this systemic context. wife/mother is given the responsibility of taking
charge of what happens "inside" the house, which
Assessment of Asian American Families includes rearing and educating children and being
responsible for financial matters. The husband
The assessment of the Asian American family assumes the responsibility of taking charge of
needs to include baseline data about the family what happens outside and hence represents the
and its members, such as place of origin, socio- whole family in the public domain. Although a
cultural background, family structure, role ex- wife seems to have little power in the family
pectations and obligatory relationships, values, system on an overt level, she has enormous psy-
basis of marriage (matched vs. romantic), birth chological power over her children, as can be
order, sex-role differentiation, support systems, illustrated by an observational comment: "While
communication patterns and style, child-rearing the husband thinks he is the master of the home,
practices, forms of discipline, emotional expres- the wife knows she is."
siveness, marital status, educational level, oc-
cupation, socioeconomic status, treatment history,
and stability of the family prior to immigration. Structural Aspects
The therapist can then assess postimmigrational
variables, such as reasons for immigration, im- Establishing and Utilizing Authority
migration pattern, language, culture shock, degree Within Asian cultures, a high value is placed
of adjustment and acculturation, the nature of ad- on respecting authority figures. Roles and rela-
justment problems, degree of flexibility and tionships (e.g., between father and son; doctor
adaptability, coping skills, generational status (e.g., and patient) are well defined, and interpersonal
first vs. third), intergenerational conflicts, dis- behaviors are governed according to rules based
crepancies between pre- and postimmigrational on them. In the mind of the Asian American,
life patterns, support systems, and other sources there is the doctor (therapist) and the patient (I.P.);
of stress and conflicts (e.g., role and status re- along with it comes the expectation that the therapist
versals). is capable of knowing what is wrong with the
client and how to "correct" or "cure" the client.
Power Structure and Distribution The therapist working with the Asian American
An accurate assessment of the power structure family can utilize these expectations regarding
in the Asian American family is crucial in the clear role definitions in the therapeutic situation
strategic sense, since the therapist may need to by providing a set of clear, specific cues that help
ally with those in power positions to bring about the family judge the therapist's expertise/authority.
certain changes in the family system. The structure The therapist, for example, can casually mention

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 Sung C. Kim

phrases such as "in my professional judgment" willful control over them (Brown et al., 1973).
or "in my experience with many similar cases." If Asian Americans indeed believe that avoiding
The therapist can also display diplomas, licenses, self-exploration is a means of becoming better, a
and books; introduce himself or herself by profes- therapeutic method which utilizes this cultural ex-
sional title and demonstrate manners congruent pectation is likely to be more effective than those
with that professional status. At the same time, that discourage it. Avoidance of self-exploration
the family members should be accorded the degree on an open, verbal level does not mean that self-
of respect and consideration that ordinarily would exploration is not a valid means of attaining certain
accompany their social status. Such a provision goals, since it can still continue on an unconscious
of clear, social cues may help the family feel at level. Self-exploration on a conscious level (e.g.,
ease and alleviate anxiety pertaining to initial con- the expression of affect and the gaining of insight)
cerns over status and hierarchy. can be viewed as only one means to an end.
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

Prior to seeing the family, the therapist can Another advantage of using directive therapy
This document is copyrighted by the American Psychological Association or one of its allied publishers.

acquire therapeutic power inherent in being the with Asian Americans relates to their cultural ex-
authority by obtaining sufficient preliminary in- pectation for receiving directives. Hsu & Tseng
formation about the I.P. and the family in clinical, (1972) observed the Chinese culture to be saturated
social, cultural, and immigrational areas. The with advice-giving through magical devices such
pretherapy information gathering is particularly as diviners, geomancy readers, and physiogno-
applicable if the I.P. is being referred through an mists, mediums, and fortune tellers. They state,
inpatient setting (as is frequently the case). Ob- "It is no wonder that non-directive forms of therapy
taining information prior to seeing the family can are largely ineffective. If a Chinese imbued with
have various advantages from the strategic-struc- folk religion finally does decide to seek therapy,
tural point of view. 1) The therapist who is in the expectation will be that specific advice will
possession of information can take on the role of be given about how life is to be conducted. Any-
being an authority who can provide understanding, thing less than this is likely to be interpreted as
empathic statements about the family's problems, indifference and lack of caring."
frustrations, shame, and pain, and offer some
plausible reasons or explanations (even tentative) Structuring the Initial Session
for the "cause" of the problem, rather than seeming Preferably the therapist should see the whole
to be a novice who relies on asking instead of family, at least for the first time, so that the in-
giving. 2) The immediate relevance of a detailed teraction among family members can be enacted
evaluation interview, if conducted in a traditional and observed. However, there are many instances
manner, may not be readily acknowledged by the when this would not be possible or wise. One
family, especially when the family is in crisis and cannot be too dogmatic about a particular format
expects immediate solutions. 3) Given the limited in doing family therapy both on theoretical and
time, any information gathering during the initial pragmatic grounds, since multiple realities of Asian
session reduces the time spent in providing "ther- American families cannot befittedinto standardized
apy." 4) Prior knowledge about previous hospi- formats. The notion of structuring the initial session
talizations, therapeutic experiences, and the type flexibly is practiced by most family therapists;
and form of therapy received can yield valuable however, its relevance needs to be reemphasized
information about what to utilize in the future in the context of the Asian American family.
sessions as well as what is contraindicated. In this Once the family is gathered for the first session,
way, the therapist can "pace" with the family's
the therapist can structure the therapy as one which
(culturally conditioned) expectations by utilizing
may require sessions with the whole family, sub-
information to build credibility as the knowl-
systems, or significant others, at different stages
edgeable authority who can offer help and hope.
of therapy, depending on the judgment of the
therapist. Reiko (1982) reiterated the importance
Taking the Directive Stance of therapistflexibilityby stating that family therapy
The directive approach of strategic-structural with Asian Americans does not always require
therapists may be compatible with many Asian all-encompassing family involvement. Similarly,
American values and beliefs. One belief is that Lee (1983) suggested a "flexible sub-family system
an individual should not dwell on the self or on approach." With this open-ended, flexible setup
morbid thoughts but should avoid them and have (covering all contingencies), the therapist has the

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 Family Therapy for Asian Americans

freedom to be flexible, without unduly alienating the social and power hierarchy as prescribed by
some family members if another format is clinically the given Asian culture would be the safest way
warranted. to begin the family therapy. Although the power
The first session is probably most crucial in distribution within a particular family may not be
determining whether the family will return for distributed along the culturally idealized/prescribed
other sessions. The structure of the traditional line, this initial move on the part of the therapist
one- to two-hour family session can interfere with 1) shows the family the therapist's respect for and
the engagement process. Much of the first session familiarity with the family's dominant value sys-
is typically taken up by evaluation questions and tem; 2) does not take a chance of antagonizing
observation of family organization, interactive and thereby disengaging certain family members
network, and dynamics, leaving little time to "do from the therapy; and 3) enables the therapist to
therapy." In spite of the initial understanding that see the discrepancy between the culturally pre-
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

this is merely an evaluation session, the family scribed family organization and the actual family
This document is copyrighted by the American Psychological Association or one of its allied publishers.

may assume mistakenly that what happened in organization. Addressing the family members in
the first session will happen in other sessions and this manner can serve both assessment and therapy
thus feel severely disappointed with the results of functions.
the family therapy. The family may weigh their The structure of many Asian languages is gen-
perception of what happened (generally negatively, erally not conducive to conducting family therapy
given a strong cultural expectation to receive in an egalitarian, open, direct, and conjoint fashion.
something substantial and tangible) against the For example, Japanese and Korean languages have
concerns about confidentiality, shame, time, and an elaborate honorific system with multiple forms
money. In other words, the family may mistake of addressing others depending on their status,
the assessment session for the totality of the therapy age, and sex. The language structure to a large
experience. extent reflects the cultural reality and needs to be
As a way of overcoming this potential mis- respected and worked with, rather than challenged.
perception, allowance for an extended period of Implications of the linguistic structure vis-a-vis
time for therapy is often necessitated, where the family therapy with Asian Americans need to be
therapist does not base the end of the session on seriously examined.
the clock time but on clinically meaningful phe- It is recommended that the therapist "protect
nomena (e.g., a sense of instilled hope, a sense the parent's face" until he or she has gained the
of understanding the identified patient's problem, necessary "authority" in the parents' eyes and
a strong faith in the therapist's ability to help). until the therapeutic relationship is strong enough
Increasing the frequency of therapy sessions may to withstand confrontation. In this respect, starting
be necessary in the beginning phase of therapy the discussion of the problem with a family member
(to capitalize on the motivation/pain inherent in who is lower on the hierarchical ladder will at
the act of help-seeking and to mobilize the height- best meet with resistance in the form of confusion
ened energy induced by crises). Frequently parents and shame on the part of those higher in the hi-
bring the I.P. and then demand that the therapist erarchy. Such a move will most likely succeed in
talk the I.P. out of the problem. Perhaps uncon- undermining the therapist's credibility, since, in
sciously, they want the therapist to have the same the parents' minds, the therapist either does not
failure experience that they have had. A way of understand the Asian culture or disrespects the
potentially avoiding such a trap is to let the family age-old tradition and values.
know, from the beginning, that the therapist will
not offer a premature solution. The therapist may Goal Setting
offer some tentative formulations (in order to stra- Lee (1983) recommended a family therapy ap-
tegically meet the family's cultural expectation proach which is "problem-focused," "goal-ori-
for immediate solutions) but be definitely clear ented," and "symptom-relieving." Rather than
that unless the right solution for the serious problem defining goals as expressions of anger, self-as-
is found by a careful analysis of the problem, sertion, or acquisition of insights, they would be
more harm can easily come to the family. more acceptable if defined in terms of problem-
solving, tangible outcomes (such as symptom re-
Addressing the Family Members duction) on a relatively short-term basis. Goals
Addressing the family members in the order of may best be stated in terms of situational change

345
 Sung C. Kim

or external resolution (as opposed to internal res- highlighted in relationship to the concept of shame,
olution, such as emotional expressiveness, self- since one of the main functions of indirectness is
assertion, and insight acquisition). Long-term goals to maintain the other's face, not to bring on loss
may best be broken down into a series of visible, of face, not to shame the other (Shon & Davis,
achievable, interrelated short-term goals which 1983). Any therapeutic move that could be con-
are renegotiable with the family. Such an approach strued as blaming the parents or pointing at the
is not intended to minimize the importance of marital relationship may not be too successful
insights, dynamics, or emotional expressiveness, with the Asian American family, especially when
but rather to engage the family in therapy. Once it is done in front of children. Such premature
the family is engaged and the therapeutic rela- and direct confrontation by the therapist would
tionship becomes established, the therapist can typically lead parents to "lose face" and succeed
offer other options and goals in therapy. only in lowering the therapist's credibility in the
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

eyes of the family.

This document is copyrighted by the American Psychological Association or one of its allied publishers.

Strategic Aspects By the time an Asian American I.P. is brought

to the therapist, it can be assumed safely that in
Engaging the Family: Defining the Problem most cases the family has tried unsuccessfully all
With most Asian American families, the purpose other available means (Lee, 1983). In order to
of coming to therapy is for the benefit of the I.P., engage the parents, the therapist, in line with the
not the family. Due to the lack of psychological approach taken by Haley (1973), may ask them
explanatory concepts and terms in Asian cultures, to elaborate their previous, futile attempts to help
most Asian American families are either not very the I.P. The therapist may kindly reiterate the
aware of their contribution to the I.P.'s difficulties futility of the family's attempts. The unpleasantly
(either in causing the I.P.'s problem or maintaining reawakened realization of the futility of their pre-
it) or unwilling to talk about their contributory vious failures may be augmented by an awareness
roles during the initial phase of the therapy. A of what might happen if the I.P.'s problem goes
recommended approach to engage the family would unattended and uncorrected. Due to the under-
be to pace the family's cultural expectations and standable parental inclination to deny the existence
limitations by 1) asserting that the I.P.'s "problem" of the problem or the unpleasant prospect of the
(therefore not the I.P. by implication) is indeed problem becoming uncontrollable, the therapist
the problem; 2) recognizing and reinforcing the may have to take a gentle but firm stance in ex-
family's concerns to help the I.P. to change the ploring with or even verbalizing for them the po-
behavior; and 3) emphasizing that each family tential negative consequences of leaving the prob-
member's contribution in resolving the problem lem unattended or denied. Examples of negative
is vitally needed, and that without it, the problem consequences may be provided: shame, emotional-
will either remain or get worse, bringing on further ache, head-ache, and financial-ache.
difficulty for the family. In this way, the family While offering hope to the family that there is
therapy simultaneously 1) is defined as being something that can be done about the I.P.'s prob-
"problem-focused" (in contrast to I.P. or family- lem, the therapist can state that the work of re-
focused), 2) implies the family's crucial role in the solving the problem will not be easy. The therapist
resolving the problem, 3) maximizes the probabil- can predict that it will take the family's help in
ity of engaging the family, and 4) takes on a nonblam- the form of consistent, sustained, and receptive
ing attitude toward the family/parents and the I.P. participation in therapy which may not at first
This strategic approach utilizes the Asian in- appear to have visible effects, and without such
directness. The therapist can go along with the a commitment on the part of the family, the therapy
parents' perception that the I.P. is the problem, will not be useful and should not take place to
while at the same time defining the parents as begin with. The therapist, while offering definite
necessary change agents in changing the I.P.'s hope to the family, may simultaneously discourage
symptomatic behavior. However, the goal is to the family from seeking help on a "try-and-see"
direct and guide the family in such a way that the basis. This paradoxical stance may minimize the
whole family system becomes changed indirectly probability of the family "dropping out" pre-
in the process. This way, the parents can go through maturely and help them to begin therapy from a
therapeutic changes without "losing face." committed basis, anticipating obstacles predicted
The importance of indirectness needs to be by the therapist.

346
 Family Therapy for Asian Americans

Refraining fortunes) and tend to perceive the therapy as a

Reframing is a technique which may be very "one-shot deal" consultation. The notion of long-
effective with the Asian American family, since term therapy is unfamiliar to most Asian Americans
relabeling what people do in a positive way saves and may at best be viewed as a very ineffective
face and encourages change. For example, the way of dealing with problems and reinforce the
Asian American family comes to therapy with a family's tendency to deny the existence of or sup-
strong need for confidentiality, which is intimately press the problem in a fatalistic way.
tied to the concept of shame. Instead of calling
this need for confidentiality a sign of inability to Timing
trust the therapist, the therapist can point out to An aspect of strategic family therapy is its em-
family members the kind of strength they possess phasis on the right timing. For example, it would
in seeking help in spite of the strong cultural be wise for the therapist to refrain from probing
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

inhibition against doing so and assure them (re- into the marital relationship, even if it is apparent
This document is copyrighted by the American Psychological Association or one of its allied publishers.

peatedly) that their action is congruent with keeping that the relationship is at the core of the dys-
up their family's good name. This kind of approach functional family patterns. Any premature move
not only provides an accurate empathy and respect to probe, especially if the probe may sever the
for the family's subjective reality but also offers marriage, can be extremely threatening to the family
an effective reframing which minimizes the family's system. Many traditional Asians still posess a
sense of shame and feelings of lacking will-power. fatalistic view of life, especially women toward
Similarly, certain family members' self-con- marriage. The respect for proper timing on the
sciousness or reticence can be reframed as, "You part of the therapist neither precludes confronting
don't have to talk except when you want to share parents on their relationship and its effects on the
something very important. Perhaps you can learn family at a later stage of therapy nor communicating
more by listening and reflecting." "indirectly" to the parents on the real issues.
Indirect communication as exemplified by Erickson
A pragmatically useful attitude to be taken is
& Rossi (1979) can both protect the parents' "face"
that the family is "ignorant," rather than "re-
and work on their real needs on a level (uncon-
sistant." Thus, instead of confronting them via
scious) that may be more acceptable to them.
interpreting possible motivational factors, the
therapist may rely on "positive interpretation" or Many of the "resistances" observed among
"reframing." The distinction between the inten- Asian Americans (e.g., initial difficulties in trust,
tional basis and consequences of a particular action hesitancy in opening up, and tendency to give
becomes crucial to teach to the family, since much limited information) may, to a great extent, be
intergenerational conflict may be based on the mislabels for behaviors based on Asian cultural
lack of this understanding. The misunderstanding values. Openness, for example, is difficult for
between the parental generation (representing the Asian Americans who have been taught that pre-
country-of-origin values) and their children (rep- mature disclosure of emotions to a stranger (the
resenting acculturated values) may stem from dif- therapist) is a sign of lack of self-control, im-
ferent languages, communication styles, value maturity, a cause for shame, and a sense of failing
system, and expectations. one's family. In overcoming such culturally based
behaviors, the therapist may comment on the fact
Assuming Flexible, Multiple Roles that "this is only the first interview and, of course,
The term "therapist" is nonexistent in Asian there are things they will be willing to say, things
cultures and translates broadly into "doctor" or they will want to withhold." The therapist may
"teacher." Although Asian Americans typically give directives to withhold information until the
expect the therapist to be the "authority," it is family is ready to speak of them. Such an initial
necessary for the therapist to be flexible and in approach may not only be a good strategic move
possession a repertoire of skills for assuming mul- but also respects the family's world view and
tiple roles, such as teacher and guide. From tra- protects the family from revealing secrets pre-
ditional folk healing methods (e.g., fortune telling, maturely.
advice giving by ministers and priests, shamanistic Another behavior of Asian American clients is
practices), they have learned to expect immediate, the tendency to present initially with somatic
concrete, tangible products from their consulting symptoms as problems. Since emotional problems
healer/helper (e.g., advice, notes to prevent mis- are felt by them to reflect shamefully on family

347
 Sung C. Kim

upbringing, psychosomatic/somatic symptoms the problems with each spouse independently (to
could represent a more acceptable means of ex- minimize the possibility of loss of face); to negotiate
pressing psychological disturbance (Abbott, 1970; the differences between the spouses, and to in-
Sue & Sue, 1974). They may similarly come to troduce the notion of compromise; and to bring
a therapeutic situation with educational and vo- both spouses together into the final phase of the
cational concerns since these are also culturally therapy.
acceptable means of expressing emotional dis-
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entering therapy.
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(1973). Mental illness and the role of mental health facilities

The parents may also wish to view the I.P.'s
This document is copyrighted by the American Psychological Association or one of its allied publishers.

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