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Counselling Psychology Quarterly
ISSN: 0951-5070 (Print) 1469-3674 (Online) Journal homepage: https://www.tandfonline.com/loi/ccpq20
Psychotherapy utilization, presenting concerns,
and outcomes among Pacific Islander and Asian
American Students
Ofa Hafoka Kanuch, Timothy B. Smith, Derek Griner, G. E. Kawika Allen,
Mark E. Beecher & Ellie Young
To cite this article: Ofa Hafoka Kanuch, Timothy B. Smith, Derek Griner, G. E. Kawika Allen, Mark
E. Beecher & Ellie Young (2019): Psychotherapy utilization, presenting concerns, and outcomes
among Pacific Islander and Asian American Students, Counselling Psychology Quarterly, DOI:
10.1080/09515070.2019.1699502
To link to this article: https://doi.org/10.1080/09515070.2019.1699502
Published online: 06 Dec 2019.
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ARTICLE
Psychotherapy utilization, presenting concerns, and outcomes
among Pacific Islander and Asian American Students
Ofa Hafoka Kanuch
a
, Timothy B. Smith
b
, Derek Griner
a
, G. E. Kawika Allen
b
,
Mark E. Beecher
a
and Ellie Young
b
a
Counseling and Psychological Services (CAPS), Brigham Young University, Provo, UT, USA;
b
Department of
Counseling Psychology & Special Education, Brigham Young University, McKay School of Education, Provo,
UT, USA
ABSTRACT
Historically psychological research has combined Asian Americans (AA)
and Pacific Islanders (PI) into one ethnocultural group (AA/PI), thus
obscuring important group differences. We evaluated group differ-
ences in terms of psychotherapy utilization, presenting concerns,
reported distress levels, and psychotherapy outcomes using archival
data collected at a large university counseling center. Results indicated
that 443 AA clients were more likely than 415 PI clients to remain in
therapy during the first eight sessions and 100 days of treatment.
Although AA and PI clients reported equivalent levels of distress at
intake, PI clients reported more concerns related to their family of
origin –and we found some evidence of differential item functioning
on the Outcome Questionnaire-45. Both groups experienced similar
positive outcomes from therapy. We discourage the practice of com-
bining AA and PI individuals and recommend that psychology research
disaggregate data from distinct ethnic groups whenever feasible.
ARTICLE HISTORY
Received 27 June 2019
Accepted 27 November 2019
KEYWORDS
Multicultural psychology;
college counseling; mental
health services; client
retention; cross-cultural
psychology
Psychotherapy research conducted over the past several decades has shown that people
of color tend to experience higher rates of psychological distress than individuals in the
general population but underutilize psychotherapy services; they are reluctant to seek
psychotherapy until distress has become severe and drop out prematurely (e.g., Benish,
Quintana, & Wampold, 2011; Padilla, Ruiz, & Alvarez, 1975; Sue, 2003; Zane, Enomoto, &
Chun, 1994). To overcome these persistent inequities, counseling psychologists strive to
promote racial equality and support associated advocacy and social justice in mental
health settings (Carter, 2007; Olle, 2018; Vera & Speight, 2003).
Throughout the world, many counseling psychologists work in college and university
counseling centers, with increasing enrollment of students from ethnically diverse back-
grounds (e.g., Berry, Berry, Poortinga, Segall, & Dasen, 2002; Chesin & Jeglic, 2016; Smith,
Chesin, & Jeglic, 2014; Snyder & Dillow, 2015). As cultural diversity increases and the need
to attend to cultural contexts becomes more and more pressing in universities worldwide,
psychologists in these institutions have opportunities to promote understanding of
individuals from diverse backgrounds who may be at risk of not receiving needed mental
health services (e.g., Smith et al., 2007).
CONTACT G. E. Kawika Allen gekawika_allen@byu.edu
COUNSELLING PSYCHOLOGY QUARTERLY
https://doi.org/10.1080/09515070.2019.1699502
© 2019 Informa UK Limited, trading as Taylor & Francis Group
Moving beyond ethnic gloss
In order for counseling psychologists to respond more effectively to differences in
psychotherapy utilization and outcome among historically oppressed groups, a form of
historical bias needs to be addressed: the tendency to combine drastically different ethnic
groups using simplistic labels. Most clinics and mental health professionals, including
those serving college populations, still disregard ethnic identity, preferred language, and
similar criteria more specific than about four racial classifications (e.g., people with
ancestry from Africa, Asia, Europe, and Latin American –often omitting or failing to
mention indigenous cultures as well as vast cultural differences within a broad racial
group; Smith & Trimble, 2016). This practice is also prevalent in psychology research
(Trimble & Bhadra, 2013), with scholars in the U.S. inappropriately using terms such as
African American when their underlying data contain diverse ethnic groups, such as recent
immigrants from Haiti or Africa, for whom African American is inaccurate. Although the
term Latinx includes both genders (Morales, 2018), underlying data may mix individuals
originating from the Cuba, Chile, or even Brazil, with language and cultural differences
trivialized when combined. Such simplistic combination of ethnocultural groups in psy-
chological research, termed ethnic gloss (Trimble & Bhadra, 2013), gives the illusion of
homogeneity where it does not exist.
Directly related to this study, Asian Americans and Pacific Islanders access mental
health services less than other ethnic groups in North America (David, 2010; Smith &
Trimble, 2016), but current research often combines these very different groups of people.
Counseling psychologists who respond to culture-specific contexts, rather than gloss over
cultural differences, could help to improve their utilization and retention rates in psy-
chotherapy (e.g., Smith & Trimble, 2016).
Damages of glossing ethnicities
Berry et al. (2002)affirm that the meaning of human behavior is embedded in its cultural
context, integral and specific to it. An individual’s specific culture significantly influences
the development and display of human thoughts and processes. Ethnic gloss covers the
unique differences of ethnocultural groups, such that the needs of people of color remain
unaddressed and misunderstood (Hall, 1997; Marsh & Wilcoxon, 2015). Psychology
research would benefit from acknowledging the complexity of cultural influences and
cease glossing over differences by combining dissimilar populations for the sake of
convenience.
In 2000 the U.S. Census recognized Asian Americans and Native Hawaiian and Pacific
Islandersasseparateanddistinctgroups(Srinivasan&Guillermo,2000). However, much
psychology research involving Asian Americans (AA) and PacificIslanders(PI)stillcombines
these two as one homogeneous group, although the underlying cultures are remarkably
distinct (Allen, Kim, Smith, & Hafoka, 2016;Longetal.,2007). Clear differences include
languages, religious/spiritual traditions, familial and community structures and roles, and
acculturation processes (Allen & Heppner, 2011). For example, AAs tend to have lower levels
of poverty than PIs (Ramakrishnan & Ahmad, 2014), and PIs tend to have a distinct hierichal
family culture with specific roles that change with the transition to adulthood, possibly
influencing their experiences with university counseling (e.g., Else, Andrade, & Nahulu, 2007).
2O. HAFOKA KANUCH ET AL.
Previous studies have shown that, compared to other racial/ethnic groups, the combined
category of AAPI university students experience higher rates of depression and anxiety
(Lam, Pepper, & Ryabchenko, 2004). AAPI students are also the least likely of any North
American group to utilize mental health services (Abe-Kim et al., 2007; Choi & Miller, 2014;
Eisenberg, Golberstein, & Gollust, 2007;LeMeyer,Zane,Cho,&Takeuchi,2009;Smith&
Trimble, 2016). However, without disaggregating AA and PI students, it is difficult to know
how different these rates and likelihoods may actually be –and psychologists remain unable
to develop cultural-specificmodifications that have repeatedly been shown to enhance the
effectiveness of mental health treatments (Beutler, Nelson, & Castonguay, 2012;Castonguay
& Beutler, 2006; Soto, Smith, Griner, Domenech Rodríguez, & Bernal, 2018).
As one specific example of how combining AA and PI clients can be problematic, the
term “model minority”originated from the stereotype that AA individuals excel in
educational pursuits, secure stable employment, cultivate strong family ties, and experi-
ence low rates of health problems (Yee, DeBaryshe, Yuen, Kim, & McCubbin, 2007). This
stereotype would also completely misrepresent PI college students, who face distinct
challenges with educational attainment, identity development (McCubbin & Dang, 2010),
racial discrimination (Allen, Conklin, & Kane, 2017; Allen et al., 2016), trauma (McCubbin,
Ishikawa, & McCubbin, 2008), and family stress (Allen & Smith, 2015; McCubbin, 2007; Yee
et al., 2007). Hence when AA and PI individuals are combined in research, unique
differences based on cultural context are lost, and data-based inferences about
a combined ethnocultural group seem at best problematic and at worst perpetuating
misinformation harmful to both groups.
Ethnic glossing in psychology research
Our experience with the relevant psychological literature led us to conclude that the
majority of scholarly manuscripts have failed to distinguish between AA and PI participants.
To evaluatethis assumption, we conducted a systematic search using over 150 search terms
that crossed aspects of psychotherapy (e.g., counseling OR therap* OR psychotherap*) with
all nations associated with Asia (e.g., Japan* OR Korea* OR Mongolia* OR Taiwan*) and the
Pacific Islands (e.g., Tonga* OR Samoa* OR Fiji* OR Tahiti*). A search of the databases
Academic Search Premiere, ERIC, PsycARTICLES, PsycINFO,andPsychology and Behavioral
Services for publications in the year 2015 yielded 41 articles relevant to psychotherapy
including both AAs and PIs: 32 (78%) combined AA and PI participants into a single AAPI
group, and nine (22%) reported data separately for AAs and PIs. Despite the U.S. Census
distinguishing these two ethnic groups, a high majority of psychological research has
continued to combine them.
While many studies have focused specifically on the psychological health and well-
being of AAs, relatively few have focused on PIs separate from AAs (e.g., Allen et al., 2017;
Allen et al., 2016; McCubbin, 2007; McCubbin & Dang, 2010; McCubbin et al., 2008). Few
studies have explicitly compared the experiences of AA college students with PI college
students, despite the considerable cultural, historical, linguistic, and socioeconomic dif-
ferences between them (Allen & Heppner, 2011).
Considering the gap in the literature and the potential problems of combining dis-
parate groups, we sought to disaggregate data gathered from AA and PI students
receiving mental health counseling at a large university counseling center. Our primary
COUNSELLING PSYCHOLOGY QUARTERLY 3
research questions were if AAs and PIs have similar rates of psychotherapy utilization,
report similar presenting concerns at intake, report similar levels of distress at intake, and
experience equivalent psychotherapy outcomes. Because distinct cultures have different
conceptualizations of specific mental health symptoms (e.g., Berry et al., 2002), we also felt
it important to examine item responses on a widely used measure of psychological
distress, the Outcome Questionnaire-45 (OQ-45; Lambert et al., 1996). Specifically, item
discrimination describes how well an item differentiates between individuals at different
levels of distress, and evidence of differential item functioning could suggest distinct
interpretations of an item/symptom across cultures (Holland & Wainer, 2012). So our
secondary research question was to identify the extent to which OQ-45 data demon-
strated differential item functioning for AAs and PIs. We anticipated that the resulting data
would provide pertinent information regarding cultural similarities and differences in
mental health conceptualization and psychotherapy experiences.
Method
Participants
We obtained archival data from the years of 1996 to 2013 for AA and PI students receiving
mental health counseling at a large university counseling center in the Western U.S. During this
period the counseling center administered all of the measures described in the Instruments
section below to every client at intake. After 2013, this center changed its intake protocol and
no longer included several of the measures. Students in this study signed an IRB-approved
consent form at intake in which they indicated their willingness to have their de-identified
information used in future research. No compensation was provided to any participant.
Of the 708 clients included in our study, 402 self-identified as AA. The AA clients included
152 men (38%) and 250 women (62%), with a mean age of 22.0 years (SD = 3.0). Their
marital status included 247 single (61%), 131 married (33%), 5 divorced (1%), and 19 (6%)
unreported. The 306 individuals who self-reported as PI (e.g., Native Hawaiian, Tongan,
Samoan, Fijian, Tahitian, Maori) included 126 men (41%) and 163 women (53%), with 17
(5%) not reporting gender and with a mean age of 22.6 years (SD = 3.5). Their marital status
included 129 single (42%), 77 married (25%), four divorced (1%), and 93 (30%) unreported.
The average number of sessions attended for both AA and PI clients at this counseling
center was 10.9, and the modal number was two. The median treatment duration (total
number of days in treatment regardless of number of sessions) for this sample was 78 days,
with a mode of seven days. Additional information by group is reported in Table 1.
Setting
Students enrolled full time for fall and/or winter semesters and at least part time for
spring and summer terms were eligible for mental health counseling services, which
they received free of charge. During data collection clients did not have a session limit
for therapy.
While data were being collected over the span of 17 years, the number of clinicians
ranged from 21–28 full-time psychologists, 3–5 psychology interns, and 16–22 practicum
doctoral students in any given year. This resulted in a total of 320 unique individuals
4O. HAFOKA KANUCH ET AL.
providing therapy at this university counseling center, of which 179 (55.9%) were male
and 141 (44.1%) were female. Precise information about clinicians’ethnic/racial back-
grounds was unavailable, but approximately 85% identified as White/European American
and the other 15% were African American, Latinx, Native American, Asian American, and
Pacific Islander.
Clinicians in this center approached therapy with a range of modalities, including
acceptance and commitment therapy, existentialism, and cognitive-behavioral therapy.
After completing the intake forms, most students were assigned to the first available
psychologist, intern, or doctoral student. If the intake forms indicated a high severity level,
the student’s assignment was matched with the clinician’s level of competence.
Instruments
At intake, clients reported basic demographic information including gender, age, ethni-
city, citizenship, and birth country. Clients also completed all of the following measures at
the same time at intake.
Presenting problems checklist (PPC)
The counseling center for this study administers the PPC at intake to examine the
magnitude of distress that clients experience in major areas of life functioning. The PPC
consists of 43 items. The Counseling and Mental Health Center at the University of Texas
at Austin (Draper, Jennings, & Barón, 2003) developed this measure after reviewing 12
presenting concern checklists by other counseling centers to construct a comprehensive
list of presenting problems they considered non-redundant. The checklist asks clients to
“indicate the extent to which the problem is currently causing [them] distress”on
a 5-point Likert scale (0 = not at all;4=extremely) and to report “how long [they have]
had the problem”on a 6-point Likert scale (1 = less than a week;6=over three years).
Sample items include, “Academics or schoolwork or grades,”Ethnic/racial discrimination,”
and “Irritability, anger, or hostility.”
To evaluate the structure of the PPC with our ethnically diverse sample, we conducted
two separate principal components analyses, one for ratings of distress and another for
duration of the problem. In both analyses all but 8 of 43 items loaded above 0.30 on the
first component extracted, providing some evidence for the construct validity for the two
types of ratings. In a prior publication, the PPC had a Cronbach alpha of .90 (Draper et al.,
Table 1. Descriptive statistics for Asian American and Pacific Islander Clients.
Asian Americans Pacific Islanders
Variable Mean (SD) nMean (SD) nFp
Sessions Attended 11.3 (16.7) 401 9.6 (15.5) 230 1.7 n.s.
Days in Treatment 352 (525) 402 276 (534) 233 3.0 n.s.
PPC Distress 42.5 (24.2) 381 40.8 (27.4) 289 0.8 n.s.
PPC Duration 28.9 (19.2) 381 27.7 (23.0) 289 0.6 n.s.
Family Concerns 4.8 (5.0) 381 6.1 (5.9) 289 9.8 .002
Initial OQ-45 72.0 (23.7) 402 72.8 (23.8) 233 0.2 n.s.
Final OQ-45 63.1 (23.9) 402 59.1 (22.4) 233 4.3 .04
Change in OQ-45 8.9 (22.5) 402 13.6 (22.6) 233 6.5 .01
Note. PPC = Presenting Problems Checklist; OQ-45 = Outcome Questionnaire-45; n.s. = p> .05.
COUNSELLING PSYCHOLOGY QUARTERLY 5
2003). In this study the scale rating problem distress had a Cronbach alpha of .92, and the
scale rating problem duration had a Cronbach alpha of .88.
Family concerns survey (FCS)
In this study we analyzed a scale consisting of 16 items developed by the university to
assess a client’s family history of events such as suicide, divorce, and conflicts. At intake
clients reported events that had occurred across their lives by marking each item as yes,
unsure,orno. In a principal components analysis with our data, all items loaded at 0.33 or
above on the first component extracted, which provided some evidence for the scale’s
construct validity. The Cronbach’s alpha for this study was 0.79.
The outcome questionnaire-45 (OQ-45)
The OQ-45 is a 45-item self-report measure designed to evaluate psychological function-
ing and symptomatic distress (Lambert et al., 1996). Items on this questionnaire are rated
on a 5-point Likert scale from 0 (never) to 4 (almost always), with higher scores indicating
higher levels of distress. Sample items include, “I tire quickly,”“I have thoughts of ending
my life,”and “After heavy drinking, I need a drink the next morning to get going.”Four
clinical subsamples were used to establish the concurrent and construct validity of the
OQ-45, with over 92% of the subjects in each subsample being European American
(Umphress, Lambert, Smart, Barlow, & Clouse, 1997). Several subsequent studies have
confirmed the construct validity of the total score (e.g., Mueller, Lambert, & Burlingame,
1998), which was used in this study because some reports have called into question the
validity of the proposed subscales (e.g., Kim, Beretvas, & Sherry, 2010). The OQ-45 total
score has a high internal consistency reliability alpha of .93, test-retest reliability of .84,
and concurrent validity with other instruments (r=.58 to .84; Lambert et al., 1996). The
Cronbach’s alpha for this study was .92.
Analyses
To estimate client utilization rates, we obtained the annual numbers of AA and PI
clients and of AA and PI students enrolled but not receiving services in the counseling
center that year (total enrollment by ethnicity, minus clients). We then calculated odds
ratios for each year to indicate the relative likelihood of AA and PI students attending
mental health services, given their baseline proportions at the university. Accounting
for Simpson’s paradox, annual data were averaged, weighted by standard error to
account for annual variation in numbers. An odds ratio of 1.0 would indicate identical
likelihood, meaning no difference –a 1:1 ratio of AA to PI students. Odds ratios greater
than one would indicate that AAs were more likely to attend therapy than PIs (and
vice versa for values lower than one).
We conducted Cox regression analyses (proportional hazards regressions) to examine
between-group differences in psychotherapy attendance. Differences in client presenting
problems were evaluated using multivariate and univariate analyses of covariance
(MANCOVA and ANCOVA). Differences in client outcomes (changes in OQ-45 scores
over time) were evaluated using repeated measures ANCOVA.
Since the OQ-45 is widely used but was developed with samples of predominantly
White/European Americans (Umphress et al., 1997), we were interested in identifying
6O. HAFOKA KANUCH ET AL.
cross-cultural differences in item discrimination (Holland & Wainer, 2012), which in this
study would be the degree to which an item differentiates between individuals at
different levels of overall distress on the OQ-45. To evaluate possible group differences,
we conducted an item response theory analysis of differential item functioning (Cohen,
Kim, & Baker, 1993).
Results
Utilization of mental health services
To evaluate the extent to which AA and PI students were utilizing mental health counsel-
ing services available without fee at the university, we compared the AA and PI student
attendance data from the counseling center with overall student enrollment data pro-
vided by the university. About 32,000 students were enrolled each year at the university,
of which approximately 2% were AA and approximately 1% were PI.
The aggregate odds ratio we calculated with all participants was 0.91 (95% CI = 0.35 to
1.27), which indicated that in this sample PI students were 9% less likely to attend therapy
than AA students. This small difference was not statistically significant, and we observed
no consistent trends across time.
Treatment attendance
We sought to determine if AA and PI students differed in their treatment attendance
in this particular counseling center. Table 1 reports the means and standard deviations
for both groups, along with the results of unadjusted univariate analyses. However,
because clients’initial symptom severity (OQ-45 scores) may have been related to their
treatment participation, we sought to statistically control for clients’initial OQ-45
scores when evaluating treatment duration. We also included client age and date of
initial intake as covariates to account for potential differences associated with matura-
tion and changes over time.
As university counseling centers operate parallel with a university semester calendar,
we analyzed data during the first 100 days in treatment, the approximate length of an
academic semester. A Cox regression indicated that in our sample AA clients were 43%
more likely to remain in psychotherapy than PI clients (hazards ratio = 1.43; p< .05).
In a separate analysis of the total number of sessions attended, we analyzed group
differences through the first eight sessions of therapy because only about one third of
clients received more sessions than eight and because previous research has indicated
that about eight sessions constitute standard treatment exposure (e.g., Choi, Buskey, &
Johnson, 2010; Howard, Kopta, Krause, & Orlinsky, 1986). The results of the Cox regression
indicated that AAs were 31% more likely than PIs to remain in psychotherapy through
eight sessions (hazard ratio = 1.31; p< .05).
Since client termination is associated with the degree of treatment improvement, we
subsequently sought to verify if these two findings remained consistent even after
entering client change in OQ-45 scores in the models. For both the number of days in
treatment and the number of sessions, group differences remained statistically significant
COUNSELLING PSYCHOLOGY QUARTERLY 7
(p< .002). Thus the earlier discontinuation rates among PI clients than AA clients were not
attributable to changes in symptoms during treatment.
Presenting problems checklist
Clients seeking counseling services report a variety of presenting concerns, and clients’
reported level of distress and duration of distress are reported in Table 1, along with the
results of unadjusted univariate analyses. However, we sought to evaluate these two
related scales simultanouesly while statistically controlling for the possible confounds of
client age and date of intake, so we subsequently analyzed differences between AA and PI
clients on the two PPC scales using MANCOVA. The differences on the PPC between AA
and PI clients in this sample did not reach statistical significance (Wilk’s Lambda = .99, F
= 0.3, p> .05), indicating that both groups reported fairly similar levels of intial presenting
concerns after controlling for covariates.
Family concerns survey
The FCS provides information about family distress clients have experienced throughout
their lives, with scores by group reported in Table 1, along with the results of an
unadjusted univariate analysis. We sought to control for the possible confounds of client
age and date of intake, so we also conducted an ANCOVA. Results indicated that PI clients
reported more family concerns than AA clients at a level of statistical significance (F= 11.4,
p= .001). This difference was small, however, in terms of effect size (Cohen’sd= 0.29).
Examination of items indicated that compared to AA clients, the PI clients endorsed
higher incidence of parental divorce, physical abuse in the family, serious physical illness,
rape/sexual assault in the family, and family member prosecuted for criminal activity
(p< .05 for those items).
Outcome questionnaire-45 intake scores and differential item functioning
Client initial distress levels reported on the OQ-45 at intake showed no statistical differences
(p> .05) between AA and PI university student clients in this sample (Table 1). Nevertheless,
since the OQ-45 evaluates 45 distinct mental health symptoms and since the expression of
specific mental health symptoms is known to differ across cultures (e.g., Berry et al., 2002), it
was possible that the equivalent overall average on initial OQ-45 scores might have masked
meaningful differences between groups on specific symptoms. To evaluate item discrimi-
nation across groups we analyzed differential item functioning (Cohen et al., 1993).
Differential item functioning (DIF) indicates that individuals in groups have different
probabilities of endorsing an item (Holland & Wainer, 2012). For instance, when indivi-
duals from different cultures score as having the same overall level of a mental health
symptoms but consistently report different scores on one item (e.g., distinct cultural
interpretations of that symptom), that item has DIF.
As the OQ-45 items are rated on a 5-point Likert-type scale (polytomous data), we used
a graded response model in our analyses (Cole, Turner, & Gitchel, 2019). Using the
likelihood-ratio test to detect DIF (Kim & Cohen, 1998), we found that only six of the 45
items demonstrated DIF (p< .01). Four positively-worded items about (a) happiness, (b)
8O. HAFOKA KANUCH ET AL.
feeling loved/wanted, (c) enjoying spare time, and (d) feeling satisfied with life were much
more discriminating of overall distress for Asian Americans than they were for Pacific
Islanders. On the other hand, two negatively-worded items about frequent arguments
and about working too much were more discriminating of overall distress for Pacific
Islanders than they were were Asian Americans. In fact, the item about working too much
did not discriminate overall distress among Asian Americans, with response curves
indicating that Asian Americans endorsing this item had slightly lower overall distress
while Pacific Islanders endorsing this item had slightly higher levels of distress, as would
be expected.
Psychotherapy outcome
To evaluate client outcomes in therapy as a function of change in OQ-45 scores from
intake to termination, we first calculated the percentages of clients experiencing reliable
improvement (decrease ≥14 points; Lambert, 2015): 37% for AAs and 43% for PIs. Of the
remaining AA clients, 34% experienced symptom reduction of less than 14 points, 22%
experienced symptom increases less than 14 points, and 8% experienced reliable symp-
tom increases of 14 or more points. Of the remaining PI clients, 30% experienced
symptom reduction of less than 14 points, 19% experienced symptom increases of less
than 14 points, and 8% experienced symptom increases of 14 or more points. To control
for possible differences across participant age and date of intake, we conducted
a repeated measures ANCOVA. The results showed that both groups improved across
time (F= 5.0, p= .03), with the corresponding effect sizes of d= .40 for AAs and d= .60 for
PIs. Although the unadjusted difference between groups was notable, it did not remain
statistically significant after inclusion of the covariates (F= 0.8, p> .05).
Discussion
Given that human behavior is eminently associated with the specific cultural context in
which it occurs (Berry et al., 2002), this study investigated the distinct experiences of AAs
and PIs in a university counseling center. Specifically, we examined differences between
AA and PI college students in terms of their (a) utilization of mental health services, (b)
presenting concerns, (c) level of initial distress at intake, and (d) treatment improvement
rates. We also evaluated ways in which AAs and PIs responded to questions about their
emotional distress on the OQ-45. The data indicated some similarities and some impor-
tant differences.
Utilization and completion of mental health services
For a variety of reasons, persons of color of all ages tend to underutilize psychotherapy
(Hall, 1997; Lindsey, Joe, & Nebbitt, 2010; Marsh & Wilcoxon, 2015); researchers have
found that AAs underutilize psychotherapy more than any other group in North America
(David, 2010; Smith & Trimble, 2016). Our data regarding therapy utilization rates found
that PI students were 9% less likely to attend therapy than AA students, however this
difference did not approach statistical significance. This finding is consistent with other
research (Allen et al., 2016; Locke et al., 2011), suggesting that AA and PI students tend to
COUNSELLING PSYCHOLOGY QUARTERLY 9
utilize psychotherapy at comparable rates. These utilization rates were only slightly lower
(6% for AAs and 15% for PIs) than White/European Americans at the same university
(Stokes et al., In press).
Prior research has indicated that people of color who have entered mental health
treatment tend to terminate prematurely (Benish et al., 2011; Smith & Trimble, 2016). We
found statistically significant differences in psychotherapy continuence between AA and
PI clients. Controlling for demographic variables and initial symptom severity, AA clients
were more likely than PI clients to remain in treatment during the first 100 days and
during the first 8 sessions.
Although the reasons for earlier termination among PI clients in this sample remain
unknown, we hypothesize two plausible explanations. AA culture includes high levels of
respect for authority (Leong, Lee, & Kalibatseva, 2016), so AA clients may have remained in
treatment longer to show respect for their therapist. It is also plausible that PI clients did
not perceive therapy as helpful as the AA clients or that they sought out support from
other sources. PIs tend to rely on their families, those who share their cultural/spiritual
values and beliefs, and members of the larger PI community for emotional support (e.g.,
McCubbin, 2007), and PI clients in this sample might have availed themselves of such
resources more than AA clients. Both of these possible explanations remain speculative, as
we were unable to ascertain exit information concerning treatment termination from
either group. We encourage future researchers to examine reasons for relatively early
treatment termination among PIs.
Presenting concerns, initial distress, and treatment outcomes
Although previous research has shown that PIs tend to turn to their family for help
and guidance when dealing with emotional issues (e.g., Allen & Heppner, 2011;
McCubbin, 2007), in this study family problems seemed to contribute to the distress
causing PI clients to seek counseling. On the Family Concerns Survey at intake, PIs
indicated higher rates of parental divorce and family physical abuse than did AAs.
Parental use of physical discipline with PI children has been documented in the
literature (Pereira, 2010), perhaps seeming normative for some PI clients. However,
the higher rates of reported distress associated with physical discipline in their families
appears to indicate that PI clients in our sample considered these occurrences proble-
matic, at least more problematic than did AA clients.
PI clients also reported significantly higher rates of family members with debilitating
illnesses. This finding is consistent with statistics comparing PIs with the general popula-
tion in North America, reporting disproportionately higher risks of obesity (35%), cancer
(24%), heart disease (20%), stroke (11%), and diabetes (6%) (Empowering Pacific Islander
Communities & Asian Americans Advancing Justice, 2014). Thus PI students may carry
additional stress from worrying about the health conditions of their family members.
Previous research suggests that university students of color have concerns about
family problems and sexual assault (Anders, Frazier, & Shallcross, 2012). Our data indicated
that PI clients expressed this concern regarding their family more often than did AA
clients. However, the manner in which this question is phrased (“rape/sexual assault in the
family”) makes it difficult to ascertain if PI clients were reporting on their own experience,
the experience of their immediate family, or the experience of extended family. As PIs
10 O. HAFOKA KANUCH ET AL.
often use the term family to extend beyond immediate family members (Allen et al., 2016;
McCubbin, 2007), it is plausible that a broad inclusion of extended family may account for
the higher occurrence reported on this item. The alternative possibility that sexual assault
may occur at higher rates among PIs could be evaluated in future research.
PI clients also reported more occurrences of family members being involved in criminal
activity than did AA clients. Again the imprecise use of the term family may partially
account for this difference, but data from the State of California show that between 2000
and 2010 the incarceration rate for PI individuals increased 192%, a rate greatly exceeding
the 29% increase of PI individuals living in the state during that decade. This increase may
be part of the larger current trend of mass incarceration of people of color (Mauer, 2011).
Given the large extended networks characteristic of many PI families, by the time PI
students attend college they may be more likely than those of other ethnic groups to
know someone in their extended family who has experienced incarceration.
In addition to exploring differences on the FCS, we examined initial responses to
the PPC and the OQ-45. We found no statistically significant difference between AA
and PI clients on either of these instruments, indicating overall equivalent levels of
emotional and psychological distress at intake. Moreover, psychotherapy was effective
for both AA and PI clients, with levels of distress on the OQ-45 decreasing over time at
comparable rates after controlling for age and number of sessions attended. Therapy,
at least at this particular university, tended to benefit both groups, but sizeable
percentages of clients did not benefit from therapy. We are concerned that 30% of
AAs and 27% of PIs reported more symptoms on the OQ-45 at termination than they
did at intake, and we recommend that future psychotherapy outcome research with
clients of color not only evaluate mean scores but also report data distributions
inclusive of clients who do not improve in treatment.
Specific symptoms of psychological distress
Given cultural differences in conceptualizations of psychological distress (Nguyen &
Anderson, 2005; Long et al., 2007; Yee et al., 2007), we sought to ascertain how PIs and
AAs responded to the items of the OQ-45. Results indicated that both groups similarly
endorsed 87% of the items. Although this finding provides some indirect support for the
cultural equivalence of the OQ-45 (Lambert et al., 1996), future research will need to
specifically evaluate that possibility.
Interesting patterns emerged for the six OQ-45 items that demonstrated DIF. AAs and
PIs tended to respond differently to positively worded items regarding happiness, feeling
loved/wanted, enjoying spare time, and life satisfaction. Those four items more strongly
predicted total OQ-45 scores among AAs than among PIs. It is possible that PI individuals
may consider psychological distress to be relatively distinct from those kinds of positive
emotions, in part because of a general cultural emphasis among PIs that fosters inherent
joy in the moment and overt displays of positive affect (Māhina, 2008; Mindess, 2006). This
finding may also imply that PI clients may feel temporary distress but overall happiness
and life satisfaction (or low distress and also low life satisfaction). Similarly, it could be that
cultural values softening overt emotional expression among AAs (e.g., Long et al., 2007)
could make the expression of strong positive emotions even less likely under distress. In
COUNSELLING PSYCHOLOGY QUARTERLY 11
short, cultural norms regarding emotional display may impact internal emotional
experiences.
The analyses also revealed differences between AA and PI clients in their responses to
two OQ-45 items about (a) frequent arguments and (b) working too much. Those two
items were much more predictive of overall distress for PIs than AAs. It is plausible that
a lower rate of public argument among AAs compared to PIs may partially explain the first
finding (Leong et al., 2016; Yee et al., 2007), but it is also possible that PIs who engage in
frequent arguments may be more likely than AAs to do so out of psychological distress
rather than for other reasons (e.g., differences of opinion). These and other possibilities
warrant future consideration. The second finding of differences on the item evaluating
perceptions of working too much provides an even more compelling area for future
inquiry. Asian American cultures tends to value productivity and hard work (e.g., Long
et al., 2007), such that associated behaviors may have mixed associations with distress
(e.g., individuals not working particularly hard may feel that they need to work harder, and
individuals working excessively hard may experience personal satisfaction from doing so).
Perceptions of working too much were associated with distress among PI clients. Overall,
differences between AA and PI clients on OQ-45 items occurred infrequently but those
differences that were observed seemed to be relevant to underlying cultural factors.
Study limitations
Because the current study was conducted at a single university counseling center, results
are not generalizable to other settings. Moreover, we were unable to gather more
information regarding clients’level of ethnic identity development, acculturation, and
socioeconomic background, all of which might have substantially influenced the therapy
received. Using archival data, we were unable to ascertain whether therapists and clients
had agreed upon termination or if the clients had dropped out of treatment prematurely,
even if the data indicated that the group difference in termination was independent of
symptom change.
Since the data in this study were self-reported, there are likely other limitations.
Although the PPC and the OQ-45 measure the client’s level of distress at intake, the FCS
requires that clients remember experiences from early childhood/adolescent years. Thus
responses to this survey may not have been completely accurate if clients were embar-
rassed or hesitant to reveal certain family traumas. Also earlier memories may have
diminished over time.
Measures used in this study were not normed for AA or PI populations; thus these
measures may not represent accurate accounts of their experiences. For example, word-
ing of several items on the FCS did not specify whether the question was to be applied to
the respondents’own experiences of trauma or experiences of others in their family;
answers may have varied according to how each respondent interpreted the question. We
encourage future researchers to use instruments normed for these specific populations
whenever possible.
Finally, we recognize that we have engaged in ethnic glossing by using the broad
terms Asian American and Pacific Islander. Dozens of distinct ethnic groups fall under the
broad umbrella term Asian American (Long et al., 2007), but we lacked participants of each
ethnicity to conduct sufficiently powered statistical analyses. We also lacked sufficient
12 O. HAFOKA KANUCH ET AL.
data to analyze multiple ethnic groups combined as Pacific Islanders. Although our data
demonstrated important distinctions between AA and PI clients, future research will need
to collect data from larger research samples. For instance, given the relatively small
numbers of Malaysian Americans or Fijian Americans at a single university or clinic, data
collection will need to include multiple sites, statistically controlling for differences across
sites.
Implications for practice
With increasing diversity of students and increasing severity of mental health concerns on
college and university campuses across the U.S. (e.g., Snyder & Dillow, 2015), counseling
psychologists and other professionals need to focus on the specific needs of ethnically
diverse students. Although abundant information is available to mental health profes-
sionals regarding AA clients, information regarding PI clients is much more sparse.
Clinicians will benefit from seeking out research findings and recommendations for
practice with PIs and with other relatively small populations that have been consistently
overlooked in the literature.
Considering the overall underutilization of mental health services by both AA and PI
individuals (e.g., Smith & Trimble, 2016), we strongly encourage mental health profes-
sionals to reach out to these students on campus (through multicultural student services,
AA and PI student clubs, etc.). More specific to this study, PI clients were less likely to
remain in therapy even after controlling for symptom change (an indication of likely
premature discontinuation), so we recommend that mental health professionals take
steps to mitigate the risk of treatment attrition among PI students, such as incorporating
recommendations for culturally appropriate treatment (e.g., Smith, 2010). Prior research
has shown that culturally adapted therapy is much more effective than traditional therapy
that does not explicitly account for clients’culture (e.g., Griner & Smith, 2006; Soto et al.,
2018). In addition, we invite counseling centers to learn the specific reasons why PI clients
tend to discontinue therapy. Though our findings do not provide specifics on why PI
students discontinue therapy early, it seems particularly important that therapists be
aware of the shortened time period they may have and work to establish a strong
therapeutic relationship early on with PI clients.
Our data also indicated that client conceptualizations of distress occasionally differ
across cultures, such that clinicians should specifically inquire about clients’experiences
and expectations in therapy. As one example pertinent to the findings of this study,
clinicians working with AA clients on college campuses could ask clients to what extent
their present work load causes personal distress, rather than assuming anything.
Furthermore, an absence of reported positive emotions among AA clients may signal
high levels of distress, but clinicians working with PI clients should not assume that overt
expressions of positive affect indicate a lack of underlying distress. Our data also indicate
that clinicians working with PI clientswould benefit from inquiring about family distress
and interpersonal arguments, with frequent arguments being indicative of overall dis-
tress. Clinicians informed about cultural norms, particularly regarding emotional expres-
sion, can inquire about clients’experiences in ways that align with clients’expectations.
Although AA and PI clients reported equivalent levels of distress at intake, PI clients
reported more concerns related to their family of origin. Given these results, we
COUNSELLING PSYCHOLOGY QUARTERLY 13
recommend that future psychotherapy research explicitly assess the experiences of PI
individuals in their family context. Traditional intake protocols have focused on the
experiences of the individual client, but for some it would be culturally appropriate to
consider clients’social and family networks. A psychologist may not think to inquire about
how parental divorce, family illness, or a relative’s incarceration impacts a client’s pre-
senting symptoms. Thus instruments such as the Counseling Center Assessment of
Psychological Problems (CCAPS; Locke et al., 2011) might be administered in university
counseling centers to facilitate identification of specific presenting concerns that might
be missed otherwise.
Finally, clinicians can take some confidence that, on average, their work with AA
and PI clients results in positive outcomes. Our data indicated that both groups
improved in psychotherapy at equivalent rates, although the effect sizes were smaller
than the magnitude of those found in meta-analyses involving general populations
(e.g., Wampold & Imel, 2015). Improving psychotherapy outcomes to be completely
equitable across different ethnic groups remains a goal for the entire profession (Smith
& Trimble, 2016).
Conclusion
AA and PI clients in this study shared some similarities but also had some key differences
in terms of their presenting problems, continuance in counseling, and their conceptua-
lizations of psychological distress. We encourage counseling psychologists and other
mental health professionals who work with AA and/or PI individuals, including college
students in counseling centers, to work toward better understanding the unique experi-
ences of individuals from specific ethnic groups. When possible, mental health profes-
sionals can strive to meet the specific treatment needs (Soto et al., 2018) of the diverse
clients whom they serve.
Disclosure statement
No potential conflict of interest was reported by the authors.
Notes on contributors
Ofa Hafoka Kanuch is an assistant clinical professor in the Counseling and Psychological Services at
Brigham Young University. She is of Tongan heritage and was born and raised in the islands of
Hawai'i. She received her bachelor of arts degree in Psychology from Brigham Young University-
Hawaii and her Ph.D. in Counseling Psychology from Brigham Young University. As a Tongan-
American woman, she is committed to serving minority populations, namely Pacific people, in her
research and practice.
Timothy B. Smith is a professor of counseling psychology at Brigham Young University and a Fellow
of the American Psychological Association.
Derek Griner is board certified in counseling psychology and holds a joint faculty appointment with
Counseling and Psychological Services and the Counseling Psychology doctoral program at
Brigham Young University (BYU). Derek is committed to furthering knowledge surrounding
diversity, has conducted clinical work and research in this domain, and has received APA’s
14 O. HAFOKA KANUCH ET AL.
Division 17 Outstanding Contribution to Scholarship on Race & Ethnicity Award as well as APA’sJeffrey
S. Tanaka Memorial Dissertation Award in Psychology.
G. E. Kawika Allen leads the Poly Psi Team research efforts involving Polynesian Psychology
Research. He is currently an assistant professor in the counseling psychology doctorate program
at Brigham Young University. His research areas involve spiritual, cultural, and indigenous ways of
healing in psychotherapy including appropriate psychotherapies and interventions for Polynesians/
Polynesian Americans, as well as examining the intersections of religiosity/spirituality, coping/
collectivistic coping, depression, anxiety, and psychological well-being/adjustment among
Polynesians/Polynesian Americans.
Mark E. Beecher is a licensed psychologist and clinical professor in Brigham Young University's
Counseling and Psychological Services. He is board certified in counseling psychology (ABPP) and
endorsed as a certified group psychotherapist (CGP). Mark's research interests include individual
and group psychotherapy (emphasizing practice-based evidence), multiculturalism, disability
issues, and psychological and psycho-educational assessment.
Ellie Young is an associate professor in the Counseling Psychology and Special Education
Department at Brigham Young University. She is the graduate coordinator of the school psychology
program and teaches a variety of courses for school psychologists.
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