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INTRODUCTION Why I became interested in this study

THERAPIST CHARACTERISTICS THAT FILIPINO AMERICANS PERCEIVE AS SALIENT FACTORS IN EFFECTIVE PSYCHOTHERAPY. INTRODUCTION Why I became interested in this study. SIGNIFICANCE.

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INTRODUCTION Why I became interested in this study

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  1. THERAPIST CHARACTERISTICS THAT FILIPINO AMERICANS PERCEIVE AS SALIENT FACTORS IN EFFECTIVE PSYCHOTHERAPY INTRODUCTION Why I became interested in this study

  2. SIGNIFICANCE • it is predicted that by the year 2050, racial “minorities” or people of color will exceed the number of Whites, or “Caucasian Americans” in the United States (Sue & Sue, 2003). • Specifically, Asians and Pacific Islanders are projected to constitute 40 million of the US population by the year 2050 (Bell, 1996; US Bureau of Census, 1992).

  3. 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).

  4. 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).

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

  6. Theme 1: Empathy, Being non-jugemental, and Attunement • The most common features identified by all eight respondents are Empathy, Non-Judgementalness, and Attunement • The respondents stated that the most coveted characteristics that their ideal therapist’s possess 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.”

  7. “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 I would look at as genuinely interested to listen to my troubles.”

  8. Literature Review • The findings of this study correlate with outcome research that reveals that 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

  9. Theme 2: Unconditional Positive Regard • The overall consensus among the eight participants is that being “judgmental, insensitive, feeling forced, and being cut-off” are detriments in the therapy process. • One respondent summed it up as “the genuineness of, the innate compassion of the therapist and being objective and non- judgmental.” • “Typical characteristics, such as 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”.

  10. Rogers (1951) asserted that having an unconditional positive regard for the client is essential in any therapeutic endeavor-whether in individual, couples, family or group therapy. • Rogers (1957) posed the question: “Do we tend to treat individuals as persons of worth, or do we subtlety devalue them by our attitudes and behavior?

  11. 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).

  12. Theme 3: Therapeutic Alliance • All eight of the respondents recognized that 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.”

  13. Bordin (1979, 1984) describes alliance as “a conscious, collaborative relationship between the client and the therapist.” • An effective therapeutic alliance entails agreeing on tasks and goals, having a reciprocal regard for each other, experiencing an emotional connection, and an implicit trust that the therapist is genuinely invested in achieving the client’s goals • Some authors ( Hersoung, Hoglend, Havik, VondderLippe, & Monsen 2009), support this concept stating that therapist’s who are “distant, hostile, disconnected or indifferent” negatively impacted the quality of the therapy process

  14. Existing research correlates with the findings in this study which states that therapeutic alliance has been determined to be positively correlated with treatment efficacy in various modes of therapy, whether it is individual therapy for cocaine abuse (Glazer, Galanter, Megwinoff, Dermatis, & Keller, 2003), • couples in emotionally focused therapy (Johnson & Talitman, 1997), cognitive-behavioral treatment of children with behavioral problems (Kazdin, Marciano, & Whitley, 2005), • retention of couples in conjoint alcoholism treatment (Raytek, McCrady, Epstein, & Hirsch, 1999), • or in multidimensional family therapy with substance-abusing youths and their parents (Shelef, Diamond, Diamond, & Liddle, 2005). • The alliance in and of itself seems to have therapeutic components due to the connection forged between client and therapist that involves team work and an accepting attitude that allows collaboration and acceptance, providing a form of treatment that is useful its own right (Patton, Kivlinghan, & Multon, 1997).

  15. Furthermore Horvath and Symonds (1991) revealed that based on 24 clinical studies involving diverse forms of individual therapy, alliance was credited for 26% of the variance when looking at results, inferring that alliance is a noteworthy predictor of individual therapy outcome (Horvath, 2001) • These results demonstrate that alliance is consistently related to efficacy and that, if a strong alliance is instituted, the relationship will be experienced as therapeutic. • This supports the Filipino value of pakikipagkapwa (Enriquez, 1992) which connotes a deep interpersonal connection, communication, empathy, and understanding (Pe-Pua & ProtacioMarclino, 2000) which Filipino Americans value.

  16. Theme 4: Gender • Amongst the eight respondents, only two reported having a male therapist; however one of them stated that she only saw the male therapist once for an intake and immediately transitioned to a female therapist due to feeling that the male therapist was “somewhat chauvinistic.” I don't know if he was being chauvinistic or something. But I felt that he was being judgmental and did not really offer a lot of emotional support. When I left his office, there was a feeling of heaviness. What I imagined was that when the session ends there is a feeling of hope and encouragement which I did not experience with that therapist.” • “I've tried an initial consultation interview with male therapists and it was like there was something about that experience that I feel more connected to women, it doesn't matter what ethnicity. Just any woman.” • “If you look at my history of being in therapy, I've always consciously chosen women.”

  17. Review of Literature • 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

  18. AGE • In this study, age was perceived as a barometer for experience. While the respondents generally preferred a therapist who “was older”, there was no consensus as to what the ideal age was. Studies conducted on the effect of therapist age proposes that the” impact of therapists’ age is difficult to tease out as it is confounded with experienceand other variables”. • “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. “

  19. Review of Literature • (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 researchto suggest that age or the similarity of patient and therapist contribute significantly and meaningfully to treatment outcome’’

  20. 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)

  21. Theme 4: Accessibility and Reliability • Lack of accessibility and reliability were identified as least helpful in treatment by all eight respondents • “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.”

  22. Theme 5: Cultural Competence • 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.”

  23. 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.

  24. 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).

  25. This is underscored by Tseng (2004) who related that every culture has its unique prescription of what comprises a suitable client-therapist relationship and that therapists who are unfamiliar with the world view of Asian Americans may experience “hostility, frustration, and failure during therapy” which may lead to unfavorable outcomes and potential harm to the client.

  26. Theme 6: Efficacy and Outcome • The respondents were unanimous in attributing the quality of the therapeutic alliance as the most 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.”

  27. “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.”

  28. 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).

  29. 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”.

  30. 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.

  31. 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).

  32. 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

  33. 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).

  34. 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).

  35. 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).

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