Mary Ann Franco, LMFT, Ed.D , CP Licensed Marriage Family Therapist

1. THERAPIST CHARACTERISTICS THAT FILIPINO AMERICANS PERCEIVE AS SALIENT FACTORS IN EFFECTIVE PSYCHOTHERAPY Mary Ann Franco, LMFT, Ed.D, CP Licensed Marriage Family Therapist Doctor of Education, Counseling Psychology DrMtheMFT@Gmail.com 562 212 7572 101 Atlantic Ave Suite 104 Long Beach, CA 90802

2. Why I became Interested in the Studying Filipino American Mental Health • Current studies suggest that minority groups tend to underutilize mental health services and have a disproportionally high attrition rate compared to the majority culture due to the “biased nature of these services (Atkinson & Matsushita, 1991). • Other researchers (Sue & Sue, 1990; Mays & Albee, 1992) assert that “most counseling services are antagonistic, insensitive, and oppressive to the experiences of culturally diverse clients.”

3. Several authors (Sue et al., 1992; Sue& Sue, 2003) assert that the field of psychology has been inept at providing culturally sensitive services to racial/ethnic minorities and that the services that are being provided are often ineffective and potentially harmful. • Ethnicity and race are relevant concerns to address in mental health treatment as therapists who are predominantly white will be expected to work with minority clients, particularly Asian Americans as they are a growing population in the United States (U.S., 2001).

4. Significance in Studying Filipino American Mental Health • Filipino Americans are the second largest Asian American/Pacific Islander population residing in the US, next to the Chinese Americans and is predicted to become the largest Asian American community by 2010 (Barnes & Bennet, 2002; Reeves & Bennet, 2004. • Filipino Americans are found to be the least likely group to seek psychological services as compared to other Asian clusters (Ying & Hu, 1994). • Filipino Americans are recorded to have the highest rates of depressive symptoms compared to the Japanese, Chinese and other Asian ethnic groups in the United States (Kuo, 1984).

5. Suicidal behavior is found to be prevalent among teen age Filipino Americans. One study approximated as high as 45% of Filipino American teenage girls as having seriously contemplated suicide (Wolf, 1997), which is considerably higher than the suicidal ideation of the general adolescent age group-24% of females and 14% of males (Sanchez & Gaw, 2007).

6. A study conducted on Filipino Americans diagnosed with schizophrenia found that they more commonly exhibited greater violent behavior, more bizarre ideation, and more profound delusions of persecution and delusion of grandeur than Japanese Americans diagnosed with schizophrenia (Enright & Jaeckle, 1963).

7. Abe-Kim, Gong, and Takeuchi (2004) hypothesized that Filipino Americans seek help from religious clergy at a significantly higher rate than from mental health professionals. • They found that Filipino Americans sought professional help at a substantially lower rate (2.9%) than the general population (5.8%) Kessler et al., 1997; Regier et al., 1993).

8. Nadal (2009) cautioned that ineffectual mental health treatment of Filipino Americans, may lead to further underutilization of services and an overall decrease of mental health in the Filipino American community. • Filipino families view mental and physical disorders as shameful and stigmatizing, resulting in a higher prevalence rate than accounted by literature. • Overall, studies suggests that Filipino Americans who participated in mental health treatment, had higher levels of dysunctionality and had more severe psychological disorders, when they finally sought mental health treatment (Sanchez & Gaw, 2007).

9. Filipino American Psychology • One of the most powerful cultural values that continue to shape Filipino psychology is called bahalana • Bostrom (1968) described it is as having a fatalistic mindset • Thomas Andres,1994) defined bahalana as “acceptance of sufferings and problems by leaving the solutions in the hands of God (p. 12). • Around 83% of the Filipino population is indoctrinated in the Catholic faith (Sustento-Senriches, 1997) which may partially explain the small percentage of Filipino Americans who seek professional help altogether

10. Utangnaloob • The next noteworthy Filipino value is utangnaloob which is defined as a “debt of gratitude” (Salazar, 1981, 1985b) or “the principle of reciprocity incurred when an individual helps another” (Kaut, 1961). • This tenet defines the very foundation of how Filipinos Americans’ express their gratitude and reliance on one another.

11. Pakikiramdam • Another prominent aspect of Filipino psychology is pakikiramdam or ability to interpret non verbal cues (Mataragnon, 1987). • Nadal (2004) cites the importance of indirect communication as the primary mode of expression for Filipino Americans (p.127). • A big part of Filipino socialization is having the ability to decipher and be sensitive to non-verbal cues, a kind of “emotional a priori”. (Pe-Pua & Protacio-Marcelino, 2000). • Pakikiramdamis deemed as a socially desirable skill that enables one to access others’ feelings and exercise great empathy (Pe-Pua & Protacio-Marcelino, 2000).

12. Pakikisama • Pakikisama “maintaining smooth interpersonal relations, by going along with the group or the majority decision.” • Nadal (2009) translates pakikisama as conformity and social acceptance (p, 44). • In the social setting, the goal of pakikisama is to be accepted, admired, and celebrated and to avoid calling attention to oneself or standing up for oneself (Nadal, 2009, p.44). • Oftentimes, Filipino Americans would feign agreement, acceptance or indifference to avoid an argument, conflict or disagreement (Pe-Pua & Protacio-Marcelino, 2000). • Pakikisama stipulates evading direct confrontation and is employed as a last recourse, however once employed this measure often ends in violent behavior (Cimmarusti, 1996). • The cultural mandate for respectfulness demands that people act in a cordial manner toward each other, even when it does not correspond to their true feelings (Almirol, 1981).

13. Importance of the Family Unit • A thorough assessment of the family system needs to be addressed before efficacious strategies can be implemented, as the family unit is integral in the functioning of the Filipino American client. • It is important to understand that the family is regarded with sanctity and that the nuclear family encompasses a larger extended family (Cimmarusti, 1996). • Extended kinship includes the, in-laws, siblings, aunts, uncles, cousins, and good friends of both parents (Cimmarusti, 1996). • The clan is viewed as the locus of identity development, social learning, support, and role formation and the first line of defense in problem solving (Ponce, 1980).

14. The Great Divide • On one side of the cultural divide are Filipinos and Filipino Americans who have a mass-oriented outlook (Pe-Pua & Protacio-Marcelino, 2000), which is manifested in their choice of leisure, for instance reading literature about the latest movie stars, being interested in radio and TV soap operas, and speaking Tagalog (Pe-Pua & Protacio-Marcelino, 2000). • They typically seek the help of indigenous healers for physical, mental, emotional conditions (Pe-Pua & Protacio-Marcelino, 2000).

15. On the other side of great divide are elitist Filipinos and Filipino Americans who adhere to a more westernized way of life (Marcelino & Pe-Pua, 2000). • This is evidenced by attending cultural performances, viewing American TV shows, sporting Euro American attire, and conversing primarily in the English vernacular (Enriquez, 1992). • They look down upon their fellow Filipinos whom they perceive as “low class” and belonging on the other side of the divide (Pe-Pua & Protacio-Marcelino, 2000).

16. What do Filipino-Americans Seek in a Therapist? • Empathy, being Non-Judgemental, and Attunement • Unconditional Positive Regard • Therapeutic Alliance • Gender and Age • Accessibility and Reliability • Efficacy and Outcome

17. Theme 1: Empathy, Being non-judgemental, and Attunement • the most coveted characteristics identified are“empathy, kindness, caring, genuiness, being present, compassionate, understanding.” • “We have to be comfortable with her and that she’s welcoming and respected all of us, that she maintained confidentiality and that she is fair and unbiased.” • “The most important component was compassion. Somebody who would not take sides, but somebody who would help us go through what we're going through.” • “If I feel that I can feel safe, and someone who was very warm and doesn't place judgment on you.”

18. “She's very soft spoken and you feel comfortable with her right away as soon as you start your session with her.” • “She was very compassionate and she, like, even before I say what's on my mind, it's like she could complete my sentence, or she could express my thoughts to me.” • “Someone who sees you as a person.” • “Somebody who is genuinely interested to listen to my troubles.”

19. Other researchers (Elliott, Bohart, Watson & Greenberg, 2011), assent and recommend that therapists maintain an empathic stance regardless of theoretical orientation, treatment format, and severity of patient symptomology. • Elliott, et. al (2011) stipulates that it is imperative for psychotherapists to clearly grasp their clients perceived needs by understanding their unique experiences rather than mere words. • This is exceptionally applicable to Filipino Americans who subscribe to the Filipino value of pakikiramdam (Mataragnon, 1987) wherein non-verbal communication supersedes the importance of verbal communication. It requires effective decoding of subtle cues such as eye contact, having a nervous smile, acquiescing as a way of acknowledging deference for the professional, even if true agreement does not exist.

20. Literature Review • Two of the most significant skills for successful therapy outcomes are the capacity of the therapist to maintain attentive presence and the capacity to empathize with the client (Lambert & Barley, 2001; Orlinsky et al., 1994; Wampold, 2001; Watson, 2001). • For many decades research on developmental psychology has recognized the contributions of having warm and secure bond with a caregiver as a requisite for a positive psychological development (Bowlby, 1969; Ainsworth, 1979). • Other researchers (Orlinsky, Grawe, & Parks, 1994 ) acknowledge the connection of therapist empathy in the development of secure therapeutic bonds and positive outcomes in psychotherapy

21. Theme 2: Unconditional Positive Regard • being “judgmental, insensitive, feeling forced, and being cut-off” are detriments in the therapy process. • someone who doesn’t judge, someone who's very empathic, very validating. • Someone who's there with me, and even if they don't understand, that's not the point. I think the point is just that they're present with me in whatever state I come into therapy as”.

22. Faber (2007) acknowledged that therapist of various persuasions, for instance behaviorists and cognitive behavior therapists concede that positive regard facilitates the use of technical interventions. • This is consistent with the results of 12 studies conducted by Bergin and Garfield (1971), which ascertained the link between positive regard and therapeutic improvement. • This coincides with the Filipino cultural practice of being respectful, avoiding confrontation and interacting in a cordial manner (Cimmarusti, 1996).

23. Theme 3: Therapeutic Alliance • the success in therapy is predicated on the quality of the therapeutic contact. • “The therapist and the patient work together and are committed to making improvements, to do whatever it takes to help the patient, then therapy will be successful.” • “Both therapist and patient need to be 100% committed to achieving the therapy goals.”

24. Hersoung, Hoglend, Havik, VondderLippe, and Monsen (2009), found that therapist’s who are “distant, hostile, disconnected or indifferent” strongly impacted the quality of the working alliance between client and therapist. • Their findings revealed that clients tend to favor therapists who are active, involved, responsive and supportive and were disinclined to give a high rating for therapists who were silent, less responsive, and less engaged. • The results suggest that clients are sensitive and influenced by therapist’s characteristics, and that the quality of the working alliance, significantly impacts therapy.

25. Ackerman and Hilsenroth (2003) compiled an exhaustive review of therapist characteristics and identified flexibility, honesty, respect, trustworthiness, confidence, warmth, interest, and openness, as positively influencing the therapeutic alliance. • Additionally Ackerman and Hilsenroth (2003) underscore that the personal characteristics of a therapist highly correlates to a positive therapeutic alliance, and that interventions such as exploration, accurate interpretation, and facilitating open expression of affect also enhances the therapeutic relationship. • Satir (1967) reiterates that it is imperative for the therapist to provide an atmosphere of safety and security, where the clients can feel comfortable and confident enough to begin self exploration, for treatment to be successful. • Satir (1967) suggested that in conjunction to being “very warm and supportive”, the therapist needs to communicate compassion and understanding on an impartial basis. • Cain (2002) agrees that the therapeutic relationship is the essential vehicle that promotes constructive change in the client.

26. The relationship between therapists’ qualities and attrition rate • Beckham (1992) confirmed that an active collaborative relationship wherein the therapist and client are equally involved in the goal formation, treatment modality and interventions significantly decreased the level of attrition. • Beckham (1992) found that the quality and level of rapport during the initial contact between the client and therapist significantly impacted the decision of the client to stay or discontinue treatment.

27. Pinsof & Catherall, 1986; Rait, 2000 concur that among all the dimensions of the therapeutic process that have been investigated in the literature, therapeutic alliance has appeared to be the a single most crucial element, recognized by most psychotherapists and researchers as imperative for successful treatment. • Additionally, findings coincide identifying the quality of therapist-client relationship as a strong predictor in treatment outcome across theoretical models and treatment modalities whether for individual, couple, and family psychotherapy (Garfield, 2004; Jones & Cumming, 1988; Martin, Garske, & Davis, 2000). • Menninger (1958) agrees that the degree of collaboration between the client and therapist, or “therapeutic contract” is instrumental in resolving the presenting problems as well as mutually comprehending the tasks to be delved in.

28. Theme 4: Gender and Age • Bischoff and Sprenkle (1993) revealed that there is substantial evidence that shows that gender matching of therapist and client circumvented premature termination • These perceptions are shared by some authors. Timm, T. M., & Blow, A. J.,Cox, R. (2008) "only a woman would understand what I'm going through," or “assigning all child cases to women because they are thought to be more nurturing and maternal” • Nelson (1993) examined the literature on the effect of gender in therapy and deduced that there is evidence demonstrating that female clients benefit more from female therapists • Hatcher, Favorite, Hardy, Goode, Deshetler, and Thomas (2006) found a discrepancy in empathy level between male and female therapists, where female therapists scored higher on the empathy scale than their male counterparts

29. However, other researchers (Maxie, Arnold, Reis and Brown (1999) claimed discrepant results, stating no difference in attrition rate between male and female therapists. • Several authors (Sterling, Gottheil, Weinstein, & Serota, 1998) reject the positive correlation between gender matching and enhanced outcomes in couples and family therapy . • Beutler et al (2004) surmised that recent research on this topic reveals an arbitrary relationship between therapist gender and outcome. • In a study of 5,000 clients who were treated by 71 therapists over a six year period, Okiishi, Lambert, Eggett, Nielsen, Dayton, and Vermeersch (2006) found that client progress as a result of treatment was in no way connected with therapist gender. • Vocisano et al. (2004) investigated the function of therapist characteristic among depressed clients in a large clinical trial, for which they concluded that therapist gender did not influence outcome in any significant way.

30. AGE • generally preferred a therapist who “was older”, there was no consensus as to what the ideal age was. • “Probably someone not too young just because of the experience” • “Someone about my age or a little older.” •  ”I went to therapists who were graduate students in their internships and it was very healthy and good for me to go and see them, but I noticed the difference when I did go to someone--cause my current therapist has been working for about 20 years. I could definitely feel the ease with which she conducted her therapy. “

31. (Beck, 1988) suggests that “if therapists are much younger than clients (10 years or more) outcome may be negatively impacted. • However, Beutler et al. (2004) argues that there is ‘‘little contemporary research to suggest that age or the similarity of patient and therapist contribute significantly and meaningfully to treatment outcome’’

32. If age were to be equated with experience, expertise and competence, several authors (Christensen & Jacobson, 1994; Tallman& Bohart, 1999) reported the counterintuitive and somewhat dismal finding that the impact of added experience on outcome is weak at best. • Stolk and Perlesz (1990) supplied data that students in the second year of a strategic therapy MFT training program were in fact inferior to freshman students. • It appears that simply putting in time as a therapist does not guarantee more competence and certainly not all activities after graduate school are targeted toward honing in on developing such skills (researcher, educator, program administrator)

33. Theme 5: Accessibility and Reliability • “Cancelling sessions frequently, not starting and finishing on time, not returning phone calls, lack of availability and poor location not providing ample warning when session is about to end, and having to switch to a different therapist for reasons other than lack of therapeutic gain.” • “I was seeing an intern in a practicum site. I think I was with her for about three months and then she said, this is our last session. I have to change practicum sites. I was going through my own crisis and that was a little mini trauma for me.” • “There was one time I remember, it was getting towards the end of the session, but I wasn't warned. Just when I was about to explore more, all of a sudden, time's up! I didn't have a warning so I felt cut off. So I didn't come back, of course.”

34. Establishing a framework and ground rules in treatment were deemed as essential in the psychotherapeutic process. • This is substantiated by Ackerman and Hilsenroth (2003) who recognized that honesty, respect, trustworthiness and confidence are vital components in the therapeutic alliance.”

35. Theme 6: Cultural Competence and Ethnicity • None of the respondents specified the preference for a Filipino therapist, however each of them noted the importance of cultural competence and sensitivity • “Someone who understands a little bit about my cultural background because it really had a lot to do with my issues.” • “Someone who allows me to talk about my culture. So even if she didn't really understand it, she was curious and she recognized that it would be helpful for both of us to talk more about it.” • “ I think the therapist's cultural understanding of the background definitely helps. I think passing judgment on your client isn’t very helpful at all. I've had that experience, and funnily enough, it was done by a therapist that wasn't Asian and didn't know much about Asian-American or Filipino-American background.”

36. Although there may be some discrepancy in the definition of multicultural competency across disciplines, Bean et al. (2002) and Sue et al. (1992) state multicultural competence is universally construed as involving three main facets: • (a) therapist awareness of how his or her own cultural experiences influence the formation of value judgments and potential biases; • (b) therapist understanding of the worldview of the culturally diverse client, and • (c) the therapist etiquette and use of culturally appropriate interventions (Bean et al., 2002; Inman, Meza, Brown, & Hargrove, 2004; Sue et al., 1992).

37. One meta-analysis reviewing seven studies found that clients who were matched with therapists of the same ethnicity, were less likely to drop out of therapy and more likely to stay in treatment until its completion, however, the effect was small, indicating that ethnic match alone was a weak predictor (Maramba & Nagayama Hall, 2002). • A recent meta-analysis of 10 studies evaluating the effectiveness of ethnic matching, found no significant difference between ethnic-racial matched pairs and those that are unmatched with respect to staying in treatment and overall functioning (Shin et al., 2005).

38. Literature Review • Several researchers (Ariel, 1999; Arnold, 1993; Avis, 1989; Bean, Perry, & Bedell, 2002;Cardemil & Battle, 2003; Green, 1998; Hardy & Laszloffy, 1992; Hare-Mustin, 1978; Imber-Black, 1997; McGoldrick et al., 1999) are unanimous in stating that cultural competency is a moral imperative for therapists.

39. Theme 7: Efficacy and Outcome • The quality of the therapeutic alliance was identified as a significant feature that highly correlates with efficacy • “Effective psychotherapy is when I feel that after session, I feel better, I understand my feelings better, and I look forward to having another session with the psychotherapist.” • “Evoked a sense of hope, brought about a positive change, conjured a deeper awareness and understanding of the self, and imparted a guideline to follow. “ • “Making you free. Liberating you from all these preconceived notions and allowing you to be yourself without worrying.”

40. “The rapport between the client and therapist, • “I would say a warm and safe relationship.” • “ An understanding of the client. I would definitely say that what would be the most effective in therapy is getting what the client needs or wants at the time. A supportive and safe place to be with somebody else who can help you.” • Having a roadmap on how to go about your life.”

41. Gurman and Kniskern (1978)stated that: “The ability of the therapist to establish a positive relationship with his or her clients, long a central issue of individual therapy, receives the most consistent support as an important outcome-related therapist factor in marital-family therapy” Wampold (2001) concludes that it is the individual who provides the treatment in psychotherapy that is actually far more potent than the specific type of treatment.

42. Review of Literature • The APA Presidential Task Force on Evidence-Based Practice (2006) state that it recognizes the importance of the therapist along with methodological plurality in studying clinical phenomena. • The task force concludes that the “individual therapist has a substantial impact on outcomes, both in clinical trials and in practice settings . . . The fact that treatment outcomes are systematically related to the provider of the treatment (above and beyond the type of treatment) which provides strong evidence for the importance of understanding expertise in clinical practice as a way of enhancing patient outcomes” (p. 276).

43. Previous evidence driven investigations (Norcross, 2001, 2002), identify treatment efficacy and favorable outcomes in psychotherapy, as a result of the therapeutic relationship • (Blow, Sprenkle, & Davis, 2007) attest that “the therapist is a critical component of change, and that much of the variance attributable to the therapeutic process lies in the therapist who delivers the treatment, separate from his or her specific theoretical allegiance”.

44. Strategies in Effectively Treating Filipino Americans • When conducting a psychosocial assessment, Nadal (2009) recommends inviting family members or other trusted individuals to participate in the clinical interview. • Sanchez and Gaw (2007) relate that Filipinos have a collectivist approach to problem solving and that decision making is often a family matter, and that Filipino Americans regardless of age may still turn to their families for support and guidance (Nadal, 2009). • Filipino Americans have a strong sense of filial obligation, they are expected to defer their decision making to older family members and/or parents as gesture of respect (Nadal, 2009). • Designating a spokesperson, usually one who has the highest educational attainment in the family or one who has the most seniority, or one who is viewed as the most sensible, may be helpful, especially in cases where linguistic challenges may arise, as Filipino Americans have a tendency to claim proficiency in the English language (Nadal, 2009).

45. In general, Filipino Americans are proud individuals who are exceptionally sensitive to criticism and negative feedback (Nadal, 2009). Therefore, it may be helpful to deliver comments, suggestions, recommendations, in a respectful and sensitive manner to maintain rapport and motivation. • It may be helpful to assume the role of an “expert” as it parallels the Filipino value of expressing deference to authority. • Cimmarusti, (1996) cautions the clinician from directly confronting a client, especially at the onset of treatment, as this is likely to lead to feelings of shame which oftentimes result in premature drop out

46. It is beneficial for the therapist to gain the client’s trust and sense of indebtedness as it may increase the likelihood of treatment compliance Cimmarusti, (1996). • Root (1997) reiterates the importance of establishing and maintaining rapport throughout by using small talk. • Oftentimes the client may inquire about the therapist’s family of origin, training, even asking about mutual acquaintances. If the therapist is able to successfully navigate this process by assuming a professional position yet conveying a warm, genuine personality, the client may feel at ease and motivated to attend treatment (Root, 2009, p. 331). • Cimmarusti (1996) cautions therapists from employing action oriented interventions such as enactment and role play as this may appear too intrusive and coercive. Less directive techniques such as circular questioning and reframing may be more effective as it is more congruent with their cultural style ( Cimmarusti (1996).

47. Nadal (2009) recommends positioning oneself within one to two feet from the client, and avoiding sustained eye contact, as this may be perceived as intimidating, encroaching, and possibly provoking • Keep in mind that Filipino Americans are inclined to express understanding and approval even when they do not comprehend or agree (Sanchez & Gaw, 2007). • Filipino Americans are not apt to asking questions, as this is perceived as an insult to the professional, because it means that the professional was inadequate in explaining the material (Cimmarusti, 1996).

48. Filipino Americans may invite their therapists to attend social functions as a way of conveying appreciation and strengthening the therapeutic bond (Root,1997). • It is widespread practice for Filipino Americans to present the therapist with a small gift as a token of appreciation, which if declined may result in the client feeling discouraged and slighted (Root, 1997, p 328). • Root (1997) adds that is highly recommended that therapists assume a professional image as this signifies competence and achievement (p. 228).

49. Cimmarusti (1996) concludes that a culturally competent, family-oriented clinician rather than an individually oriented clinician would more likely be successful with Filipino-American clients because the family is of prime importance in the Filipino culture. • Caution should also be taken by practitioners when espousing individualism as a requisite for mental health, as this group places a high premium on collectivistic values.

50. Conclusion • This study brought to light that Filipino Americans do not necessarily prefer employing a therapist from a similar culture however underscored the importance of respect and sensitivity to their cultural uniqueness. This revelation was positive because it seems that Filipino Americans would not rule out seeing a therapist from a different culture as long as they feel a positive bond or therapeutic alliance with them. • .