3. Research some articles about Filipino “Psycho medicine”.

(Include pictures)

Preventing Filipino Mental Health Disparities: Perspectives from

Adolescents, Caregivers, Providers, and Advocates
Joyce R. Javier, MD, MPH,1 Jocelyn Supan, MPH,1 Anjelica Lansang, BS,1 William Beyer, MPH,
MSW,2 Katrina Kubicek, MA,2 and Lawrence A. Palinkas, Ph.D3

Author information Copyright and License information Disclaimer

The publisher's final edited version of this article is available at Asian Am J Psychol
See other articles in PMC that cite the published article.

Abstract
Filipinos are the second largest U.S. immigrant population with the highest number living in Los
Angeles (U.S. Census, 2010). Despite their size, Filipinos have been described as a hidden
minority in the U.S. Previous scholars have described Filipino Americans as different from East
Asian Americans in terms of having unique cultural values and colonial history (Nadal K.L. &
Monzones J., 2010). As a result of almost 400 years of Spanish colonization, Filipinos are the
only Asian ethnic group that is predominantly Catholic (Agbayani-Siewert & Revilla, 1995).
Unlike other Asian American groups, Filipinos were also colonized by the United States for
almost half a century. Scholars have argued that this history of colonialism has had longstanding
effects, including the development of colonial mentality. Colonial mentality has been defined as
“a form of internalized oppression, in which the colonizer’s values and beliefs are accepted by
the colonized as a belief and truth of his own” (Nadal K.L. & Monzones J., 2010)
Contrary to the “Model Minority Myth”, compared to whites and other Asian subgroups, Filipino
youth have a disproportionately heavy burden of behavioral health problems, including
depressive symptoms, suicidal ideation, substance use, adolescent pregnancy, and HIV/AIDS
cases (Javier J.R., Huffman L.C., & Mendoza F.S., 2007; Javier J.R., Lahiff M., Ferrer R.R., &
Huffman L.C., 2010). In Los Angeles County, Filipino youth in grades 9–12 have higher public
school drop-out rates compared to Asians and non-Hispanic Whites (Ogilvie, 2008). Filipino
youth also have significant mental health risk factors, including parents with high levels of
unmet mental health needs such as severe maternal depressive symptoms similar to those of US-
born black mothers(Huang ZJ, Wong FY, Ronzio CR, & Yu SM, 2007) and exposure to harsh
discipline (Runyan D.K. et al., 2010; Sanchez F. & Gaw A., 2007). Among Asians, Filipina
mothers have the highest rate of severe depressive symptoms (9.6%), similar to those of US-born
black mothers (10.3%). Despite these behavioral health challenges, Filipino youth have low rates
of mental health care and preventive care utilization (Javier J.R. et al., 2007; Yu S.M., Huang
Z.J., & Singh G.K., 2004; Yu S.M., Zhihuan J.H., & Singh G.K., 2010). Filipino adults also seek
mental health services at a much lower rate when compared with other Asian American groups
(Gong F., Gage S.J.L., & Tacata L.A., 2003; Ying Y.W. & Hu L, 1994).
Given the disparity between mental health needs and service utilization among Filipino
Americans, research aimed at describing factors that influence help-seeking has grown (David
E.J.R., 2010). Cultural values that may affect mental health care utilization include bahala na, or
fatalism and collectivism. These values may lead to a lack of incentive to help one’s self and
placement of the needs of the family above one’s own personal desires, respectively (Nadal K.L.
& Monzones J., 2010). Cultural mistrust, a construct conceptualized to describe the distrust
among minority groups of White Americans and mainstream American institutions, including the
legal system, political system, educational system, and health care system, and other entities
governed or staffed by White Americans may also affect help-seeking among Filipinos (David
E.J.R., 2010; Terrell F. & Terrell S., 1981). Finally, help-seeking among Filipino youth may be
affected by negative messages from their families about seeking counseling. In a study
conducted with young adult children of Filipino immigrant parents, one participant stated that
her mother told her that “there is no such thing as counseling” and that counseling does not
reflect positively on the family” (Maramba D.C., 2013).

Community-Based Approaches to Change

The Centers for Disease Control and Prevention define community engagement as “the process
of working collaboratively with and through groups of people affiliated by geographic proximity,
special interest, or similar situations to address issues affecting the well-being of those people.”
This approach can bring about behavioral changes that will improve the health of the community
and its members by serving as a catalyst for developing partnerships and new programs and
practices (Fawcett S.B., Paine-Andrews A., Francisco V.T., & Vliet M., 1993).
One example where community engagement was used to address mental health disparities
among Filipino youth is described here. The present study was a part of a larger qualitative
investigation of the unmet needs for mental health services among Filipino youth in Los Angeles
(Javier J.R. et al., 2011). The overarching objective of the larger study, entitled “Filipino Youth
Initiative” was to identify specific unmet mental health needs and recommendations for
prevention of Filipino youth behavioral problems. Adolescents, caregivers, and organization and
community leaders were encouraged to articulate what they saw as the most pressing mental
health needs for Filipino youth and how best to create or use existing resources to prevent these
problems. Recognizing that religion is an integral part of Filipino culture, the study included
faith-based leaders in this needs and resource assessment (Nadal K, 2008). The present study
focused on the recommendations for prevention of Filipino mental health disparities by Filipino
community stakeholders (i.e., adolescents, caregivers, advocates, and providers). Specifically,
stakeholders were asked the following question: How can we prevent behavioral health problems
among Filipino youth?
In contrast to previous qualitative studies that describe the perspectives of Filipino adolescents
and caregivers (Chung P.J. et al., 2005), this study also included the perspectives of advocates
and providers as these may affect efforts to prevent mental health problems among Filipino
youth. The perspective of community members on needs and solutions is critical to increasing
the reach of efficacious behavioral health preventive interventions.
Method

Participants and Setting

This study was conducted from August 2009 to December 2010. Study participants were
recruited in two phases. Phase 1 participants served as key informants for in-depth semi-
structured interviews and included: 1) community leaders (i.e. school, church, city government)
and health/mental health/social service providers in Los Angeles County who are familiar with
the Filipino youth population, 2) Filipino youth aged 14–21 years old residing in Los Angeles
County, and 3) caregivers such as parents or grandparents of Filipino youth aged 14–21 years old
residing in Los Angeles County. We conducted semi-structured interviews (n=33) with: (1)
Filipino adolescents, ages 14–21 years old (n=16) and (2) community stakeholders, such as
caregivers, providers, and community leaders (n=17). Phase 2 consisted of three focus groups
(n=18) with: (1) Filipino male adolescents, (2) Filipino female adolescents, and (2) caregivers.
One adolescent participated in both the interview and focus group. Parents for the focus group
had a child of any age. Thus, parents who have children who were currently adults also
participated. The rationale for including parents of children of all ages, including adolescent and
adult children was so that parents could reflect on what information would have been helpful to
them when they were raising their young children. Youth, parents, and grandparents not of
Filipino descent were excluded from this study. Although inability to communicate in English
was not an exclusion criterion, all participants were fluent in English. Because the English
language is one of the national languages in the Philippines, Filipino immigrants are less
linguistically isolated than other Asian immigrants (Apisakkul M., Lee J., Huynh D., & Sunoo
G., 2006).
All adolescents and caregivers were of Filipino origin and none were multiracial. Among
providers and community leaders and advocates, 80% were of Filipino descent, including one
who was multiracial and the remainder (20%) was Non-Hispanic White or Chinese (3). The
adolescent sample included 12 females and 12 males. The caregiver sample included 3 males
(27%) and 8 females (73%) and the provider sample included 6 males (47%) and 8 females
(53%). Among adolescents, 11 were ages 14–17 (46%) and 13 were ages 18–21 (54%). Among
caregivers, one was between the ages 22–39 (9%), eight were ages 40–64 (73%), and two were
ages 65–79 (18%). Among providers, 60% were ages 22–39, 27% were ages 40–64, and 13%
were ages 65–79. The majority (54%) of the adolescents were born in the United States (13) with
the remainder being born in the Philippines (10) and Canada (1). The majority (91%) of
caregivers was parents and was born in the Philippines (10). Two-thirds of the service providers
were involved in providing specialty mental health (i.e. psychiatrist, social worker), primary care
(i.e. pediatrician, nurse practitioner), and other social services (i.e. after- school youth programs,
community health workers and managers) to Filipino youth. The remaining one-third was
comprised of representatives from churches (i.e., health ministry leader, pastor; 13%), schools
(principal, school-based clinic coordinator; 13%), and the local city government (7%).
Occupations of caregivers included: a clinical lab scientist, two retirees, administrator, self-
employed in finance, stay at home parent, engineer, two nurses, and a small business owner. The
majority of youth (71%) reported they were living in a single parent household (17) whereas the
rest reported their parent’s marital status as married (5) or divorced (2).
Recruitment was conducted using a purposive sampling strategy designed to obtain
“representative” viewpoints of stakeholders and region in a nonrandomized fashion. For the
interviews, we purposefully recruited adolescents who used mental health services (i.e.
counselor, mental health provider, or church leader) in the past and adolescents who never used
mental health services in the past (i.e., 8 adolescents per group). The majority of participants
currently resided, previously resided, or currently worked within Historic Filipinotown, located
in central Los Angeles. Historic Filipinotown was targeted because it has one of the highest
concentrations of recent Filipino immigrants in Southern California and still remains the cultural
heart of Filipinos throughout Los Angeles.

Procedure
Prospective study participants for both interviews and focus groups were identified through
various techniques, including: 1) making announcements at regularly scheduled organization
events with parents, adolescents, and providers 2) identifying designated parent representatives
and parent groups, 3) mailing letters describing the study and asking parents, community leaders,
or providers to call the PI if they would like to participate in the study, and 4) employing snow-
ball sampling techniques. Snowball-sampling techniques were used with initial respondents and
identified leaders to elicit additional participants. To assure that acquaintances do not have their
names provided to researchers without their permission, interviewees who provided names were
asked to talk to their friends about this project. Interviewees were also asked to give their friends
the PI’s contact information if they wished to enroll in the study. A flyer was given to the
interviewee to pass on to other potential respondents. The flyer was then used to contact the
research team if the referred person was interested in participating in the study. After the
potential respondent contacted the research team, the project was fully explained to him or her. If
permission to participate was granted, consent took place. Verbal informed consent was obtained
from each participant. The Administrative Panel on Human Subjects at Children’s Hospital Los
Angeles provided institutional review board approval for this study. Interview participants
received a $40 gift card and focus group participants received a $25 gift card for their
participation.
Prior to each interview and focus group, participants were asked to complete a brief demographic
survey. For the purpose of this discussion, only qualitative data will be presented to explore the
participants’ responses in depth. Participants were then asked a series of open-ended questions
regarding unmet mental health needs and recommendations for mental health prevention among
Filipino youth. Questions specific to prevention included: “How do you suggest we address the
mental health needs of Filipino youth and prevent mental illness in these youth? What venues
(i.e., clinics vs. church vs. school vs. nontraditional settings)?
After a majority of the individual interviews were completed, adolescent and parent participants
were recruited to participate in focus groups to elicit feedback regarding the most common
themes that arose from the interview phase. Focus group members were asked to specifically
address the following questions related to mental health prevention: 1) Do you agree with the
findings presented?; 2) Which findings do you feel to be most relevant to your experience as a
Filipino adolescent or Filipino parent/grandparent?; 3) Which findings do you feel to be least
relevant?; 4) One of the most common topics discussed was family and relationships with
parents. Can you describe a typical Filipino parent?; 5) If there was one thing you could change
about your parent, what would it be?; 6) What would you recommend to other Filipino parents
who want to improve their relationship with their child?; 7) If we were to offer parenting classes
or workshops to Filipino parents, what information would you include in those classes? What
venues would you offer them?; and 8) What are possible barriers to attending parenting classes?
While the predetermined probes listed above were used to guide the discussion, the moderator
was trained to elicit all relevant opinions related to mental health prevention efforts among
Filipino youth, and allowed the group members to present their own model of these issues. Prior
to conducting interviews and focus groups, each ethnographic fieldworker was given training on
how to conduct an interview, including procedures for establishing reciprocity and exchange of
information, different types of questions, the use of probes to elicit additional detail on a topic,
and techniques for dealing with errors in informant’s memory.
Each interview and focus group lasted approximately 1.5 hours and was audio taped and
transcribed verbatim. ATLAS.ti (2004) qualitative analysis software Version 6 was used to
analyze data through coding and examining relationships between and within text segments.
Individual interview and focus group transcripts were analyzed using a methodology of “Coding
Consensus, Co-occurrence, and Comparison” outlined by Wilms et al. (1992) and rooted in
grounded theory, in which theory is derived from data and then illustrated by characteristic
examples of data (Glaser and Strauss, 1967). Eight transcripts were independently coded by four
investigators (JJ, KK, JS, and WB) at a general level in order to condense the data into
analyzable units. The first author, JJ is Filipino American and two research staff members, JS
and WB are also of Filipino heritage. KK is an investigator who is non-Hispanic White with over
a decade of experience using this technique. Segments of transcripts ranging from a phrase to
several paragraphs were assigned codes based on a priori (i.e., based on questions in the
interview guide) or emergent themes. Themes were generated independently from the narrative
summaries by the first author, two research assistants and senior researcher on the project. In
some instances, the same text segment was assigned more than one code. The remaining
transcripts were independently coded by two investigators (JS and WB). Disagreements in
assignment or description of codes were resolved through discussion between investigators and
enhanced definition of codes. The final list of codes, constructed through a consensus of team
members, consisted of a numbered list of themes, issues, accounts of behaviors, and opinions
that related to prevention of mental health disparities among Filipino youth. Based on these
codes, the process of axial coding was used by the investigators to generate a series of categories,
arranged in a treelike structure connecting transcript segments grouped into separate categories
or “nodes,” with the assistance of the computer program Atlas.ti (2004). These nodes and trees
were used to create a taxonomy of themes that included both a priori and emergent categories
and new, previously unrecognized categories. Through the process of constantly comparing these
categories with one another, the different categories were further condensed into broad themes
that were organized to illustrate linkages across categories (e.g., recommendations for prevention
of behavioral health problems among Filipino youth) and within specific categories (e.g.,
location, content, and facilitators of attendance as subcategories of mental health prevention
programs).
Results
Study participants identified four major areas to focus on when developing programs aimed at
the prevention of behavioral health problems among Filipino youth. There were no meaningful
differences by stakeholder group. Each of these major areas is presented below.

Addressing the intergenerational gap by strengthening parent-child relationships

The study participants spoke repeatedly about the need to improve parent-child relationships and
encourage open communication. A parent said, “Everything starts from the parents, everything
starts at home. Your first teacher is your parent.” When posed with the question, “What advice
would you give to parents so that they can become closer to their kids?”, an adolescent who
reported use of mental health services in the past stated:
Asking how the day went kind of helps a lot…with a soft approach not like “How’s your day?”
(unfriendly tone) because honestly I don’t know any kids that are not scared of their parents. My
parents say “ it’s okay if you don’t want to talk about it” and then they would give me some
space and then I would actually go to them and start talking. Their approach is really, really
smooth and soft.
Providers also recognized the need to promote communication between parents and adolescents.
A mental health provider described her Filipino adolescent clients as being scared to turn to their
parents with their problems due to fear of their parent’s reaction and said:
I keep hearing kids saying they don’t even want to go home. “It’s so stressful at home, I’m not
heard, I get yelled at, I get spanked like I’m a child, and my parents don’t understand that I have
a personality, that I have needs.” So over and over again, kids just don’t feel like home is very
supportive and nurturing and they feel out of place, they don’t know how to communicate with
their parents or how to assert their needs.
Expression of feelings and communication between parent and adolescents were linked for the
providers in our study. One mental health provider said the following about the Filipino families
she works with:
The parenting style that we’re seeing is that they’re not encouraged to talk about feelings. It’s
really just getting good grades and then they get rewarded through money or through getting
their favorite shoes or something. But when it comes to a child crying, a parent asks, this is just
really my experience, because I’ve done family preservation, “why are you crying?” in an angry
tone. Nobody’s going to tell you why you’re crying if you sound angry. So you get something like
that and it’s not encouraged in our community at all to open up feelings. In fact, there are family
secrets that go on for a long time and more often it’s strange how some parents they don’t ever
tell their children that they were adopted, that they’re not really their real children, they never
tell the children that.
Participants also recognized the importance of parents spending quality time with their children,
monitoring their child’s whereabouts, and limit setting when raising children. For example, one
parent noted, “Parents need to spend time with their kids and have family time to bond.” One
provider also commented on the importance of quality time with children:
The fact of the matter is that all kids really need is attention especially in early childhood to
create these attachments because the major problems occur when kids feel abandoned. They feel
abandoned because their parents came over to the U.S. to make these sacrifices but they’ve lost
that bond early on with their kid, and they try to reestablish them and they say, “Well I do this
for them”…like working the 50 million jobs I mean, you know you got to do what you got to do
but then nothing pays more in dividends than just reading a book to your kid and spending real
time with them”.
Another provider described how lack of time spent with adolescents can have negative
consequences: “Teens join gangs to create a family bond that may have been missing at home.
Lack of supervision allows kids more freedom to experiment and try different things.” A
community outreach worker described the importance of providing consequences for a child’s
misbehavior:
The child is entitled to have tantrums. It may be unreasonable at times, but let him be
unreasonable because he’s a child—but he can have consequences. No cookie, no going out to
the movies this week.

Providing parenting programs as a means of preventing adolescent mental health

problems
The theme of parenting programs for Filipino youth has four major subthemes. First, a wide
range of parenting approaches were identified (i.e., permissive, avoidant, use of verbal abuse,
and physical discipline) and ways parenting classes could address them were described. Second,
outreaching to the parents of school age children was recommended. Third, offering parenting
programs to Filipinos specifically versus multi-cultural programs was suggested. Finally,
participants recognized that stigma may be a barrier to attending parenting programs.

Parenting styles among Filipinos

Participants, in particular providers, spoke of varying parenting approaches observed among
their Filipino families. A mental health provider noted that parenting styles that were effective in
the Philippines might not be as effective in the U.S.:
Traditional parenting styles that were effective in the Philippines in that context may not be as
effective in this new location, this new kind of cultural context here…In my clinically referred
sample, I see a lot of parents that have very permissive parenting styles, not because they think
everything’s okay but they have a lot of difficulties in setting effective limits with their children.
Once problems begin to arise I think they often times feel very, kind of, helpless or
disempowered as to how to effectively handle or manage their child’s behavior issues. I think the
parents often times will use shaming techniques, “you shouldn’t do that, that’s bad” or “God
will punish you for your sins.”
Another mental health provider provided examples of verbal abuse, “It’s a lot of putdowns. Your
grades are not good, you’re stupid, name calling, if the parents are divorced and it’s like you’re
just like your father who’s stupid too.” She further elaborated on the effects of verbal abuse on
Filipino youth:
It definitely brings down their self-worth and self-esteem and they become more ashamed of who
they are as a person and they stop trying. If they’re doing homework, well they just don’t want to
do it, and I think it instills fear if they show that they did something wrong. And you can tell too,
when a child is being verbally abused, like if you tell them oh do this over because this is
wrong…they just refuse to try.
She further elaborates that Filipino parents often do not realize the effects of verbal abuse on
youth:
Some parents, when it comes to the point when we tell them you have to come in because we do
have to address some issues, again it goes back to them thinking, oh but I meant well, my
intention was good. And we tell them your intention is good, but is there an alternative way that
you can express it because it really is not helping the child. We explain to them that this is the
effect when you call a child stupid or when you call anybody stupid. And we go through that with
them and they do begin to understand. Some parents when they say they mean well and then we
explain to them, this is the effects of it, (they say), “Oh I didn’t realize that.”
Another mental health provider who has provided mandated parenting classes to Filipino parents
referred from child protective services commented that physical discipline is also used:
Violence in the home is very common and child abuse…Well that’s the whole purpose of the
parenting class too. When we do get Filipino families, the first thing we talk about is the laws
here in America, because we do know that if you were born in the Philippines, a form of
discipline in the Philippines is to hit and stuff like that. The sad thing is the parents don’t realize
that it’s abuse- they think that it’ll better the child.
When asked how parenting programs could support Filipino families, a primary care provider
commented, “Parents should understand a little bit about growth and development. Simple stuff
about what to expect…and parenting skills…A lot of times, parents just go in blind…Most
parents’ parenting skills are definitely from what they emulate.” Another mental health provider
commented, “I’d love to see education on very basic attachment theory”. She further provided an
example of a Filipino client with uncontrolled diabetes that was referred to her:
After years and years of being avoidant, I actually had one Filipino woman say “I feel
manipulated” by her 20 year old daughter because she spent so many years placating the
daughter and just pacifying her or not dealing with actually mothering and parenting that after
so many years of that she became resentful, like my daughter’s manipulating me, like my
daughter’s controlling me, and then there came this frigid, angry, bitter mother that didn’t want
to hold her daughter, didn’t want to cuddle with her daughter… just very withholding
emotionally. And that’s kind of what will happen over time. You become resentful just like any
relationship where you’re not addressing emotional needs, your emotional needs, could be the
child’s, someone else’s emotional needs, people start feeling resentful about that. You’re not
giving your child any boundaries so yeah, they’re going to step all over you, they’re going to go
crazy, and then you’re going to punish them by not giving them your love.
Outreach to parents of school age children
Participants emphasized the importance of outreaching to parents before their children reach
adolescence. One provider noted:
Mental wellness is a part of everything, so let’s just talk about it now. It doesn’t matter what the
context is, it’s part of, of sending your kids to school. They need to be mentally well… And when
you first send your kids to elementary school you already have a sense of, you know, you’re
worried, you’re letting them go, and that’s a good space. That’s good, it’s right for planting
thoughts into their heads. As long as it’s culturally safe, culturally competent, and framed in a
way that’s sensitive to the community.

Use evidence-based preventive parenting programs and offering Filipino-specific groups

When a mental health provider was asked to provide feedback regarding offering parenting
workshops for Filipino parents, he shared the following:
Our agency has done some parenting classes and in general the success of them depends on how
well trained the leader is, are they trained in an evidence-based manualized program, because
just going in there and making stuff up is not likely to be effective, so you need somebody who’s
trained in a specific model and implements that effectively…I think if you had a group focusing
specifically on Filipino families, I think that might be more likely to be successful because there
would be greater identification with each other and probably a greater willingness to share
common experiences as well as the obvious language advantage.
A community advocate agreed that outreach should target Filipinos parents specifically and
noted: “I think Filipino families come out only if they are together.” Finally, another provider
stated, “I think you can do something very ‘Filipino’ and specifically reach out to Filipino
parents. I think the shame factor would come up. If it was a mixed (parenting group), they may
say oh sorry, but Filipinos are this way, a particular way.”

Barriers to attending to parenting programs

Participants noted that it is may be difficult to get parents to attend a parenting program. A faith-
based organization leader described stigma associated with parenting programs: “Some Filipinos
might say, ‘why, what do you think, that we are not capable of parenting our kids?’”
An adolescent noted that if his parents were offered a parenting program, they would not attend
unless it was a requirement for school. In addition, this participant thought his parents may be
suspicious even if something free like an incentive was being offered for attending: “Some
parents would… just ignore it. They wouldn’t want to go. Even if you offer them something,
they would say, ‘What if they’re lying to us?’ Like they’re not going to give (i.e., a free
incentive) what they are saying… If it was a requirement for us to enter school, they would
unwillingly go.” Another parent provided a suggestion to emphasize the benefits to the family in
order to encourage participation:
I think another possibility as far as getting people to try is to try to appeal to the sense of
family… Because I think that Filipino parents love their kids so much it’s ridiculous. And just
like that sense of family is so strong, and I think that’s possibly something you can touch on to
try and get people to go to that. This (program) is helping their family. This is your kids, you
love your kids…Let’s work on making things better for you and your kids.

Importance of religion and collaboration with churches

The theme of religion was divided into two subthemes. First, participants noted that religious
beliefs, such as bahala na could serve as a barrier to addressing mental health problems. Second,
participants also felt that religion and partnering with faith-based organizations could serve as a
facilitator to addressing mental health.

Fatalism as a barrier
Participants spoke of bahala na as a barrier to accessing assistance with mental health problems.
For example, one of the providers in our sample said:
I see folks who minimize their experience. They say “I don’t need to come and discuss all my
problems, I just give it to God.” And so we sort of have to look at, maybe God and whatever idea
you have of God has brought you here… and help them broaden or change that perspective.
Sometimes I hear people feel very guilty that they are even depressed or anxious because they
feel like “If I were good enough, if I were a good enough Catholic or Christian, then I wouldn’t
be feeling this way. This is a sign of my poor faith.”
Another mental health provider of Filipino-American descent described her own experience of
trying to convince her family members to talk about their problems:
A lot of my family says “oh that’s the American side of you.” And, well good! You know? So
what if I want to address this? It has to be forced …“Don’t talk about it, don’t talk about it.”
And I said, “would you rather things get worse?” And then they say, “They’ll be fine. Bahala
na.” I try to bring stories from work but they never work. It never seems to convince them, how
important it is to talk about things like that. It’s the bahala na. It’ll work out. It’ll be fine. My
uncle’s alcoholism will be fine…until he gets cirrhosis. And, my uncle’s diabetes will be fine
until he was hospitalized and went into a diabetic coma…I think part of it is hopelessness.
There’s a hopelessness that it will never change, so what’s the point? Enjoy life now.
A church leader described Filipino parents coming to him asking for assistance with their
problems with their children:
I’m sure in their mind it is: ‘if I am praying, my problem will go away…pray for my kids,
because it’s the problem he or she is in.’ But, I don’t believe much in that kind of prayer. That
the prayer will solve somebody’s problem. I believe more in professional handling.

Religion as a facilitator
A community advocate participant stressed the importance of religion by stating, “Spirituality
has so much to do with your total well-being, your health, especially your emotional and mental
health.” A parent noted that partnering with churches could be effective in the Filipino
community:
We need to be proactive as opposed to reactive…a lot of people are going to say, “Oh, I don’t
have any problems. Not my kid. It’s your kid.” But you know, overall, if this especially is
directed to Filipino parents or Filipino kids, your best bet still is going to go through the church.
It’s through the priest who’s going to say, “Hey, we’re throwing a workshop on how to build
better relationships not only with your kids, but with each other…How to understand the
cultural differences between growing up in the Philippines and growing up here, because there
are differences.”
A community leader also recommended churches for parent outreach:
I speak in churches sometimes. You have an audience that’s willing to listen and even if they’re
not outwardly participating, you know you have a captive audience and you know most of them
are going to come every week. And what that translates into is, if they come every week, you
have a way to reach them every week, you have a set announcement stage for what you want to
do.
Another parent noted that Filipinos may respond to authority figures, such as faith leaders:
I think that a lot of it has to come from a position of authority… like the priest, the doctor… We
talk about them in the Filipino culture, there’s so much respect given to someone higher up… If
the priest say, “I think you should go to this” or “I want you to go to it”, they’re more likely to
go.
A church leader with past experience offering parenting classes in churches recommended
offering parenting program in parallel with youth-based programs in church: “If we give an
invitation to the parents of Filipino children attending catechism, they usually don’t stay but if
they know that there will be some meeting for Filipino parents, they may stay.”

Importance of addressing under-recognized mental health needs of Filipino parents

Participants also noted that prevention of mental health problems among Filipino youth needs to
address unmet mental health needs of Filipino parents. One mental health provider commented:
To be a good parent and to raise a healthy kid you need to be emotionally healthy. I really wish
any kind of parenting class would incorporate the parents’ emotional well-being, and talk about
the connection between a parent’s emotion, mental health and their child’s emotion and mental
health. But it doesn’t need to be super dense, it just needs to help people realize all your stuff
you don’t deal with is going to fall on to your kids. All your emotional stuff, all your issues with
your parents, all your issues with your job, with yourself, if you don’t acknowledge it and look at
it and spend time on it, it’s going to get transferred or transmitted into your children.
A school-based mental health provider agreed and noted:
We need support for dealing with parents’ health issues and mental health issues because there
are some students that are overall okay, but, I have a lot of them who (say) “I’m really worried
about my mom. She drinks so much.” They’re physically okay and mentally okay, but they
recognize what’s going on in their families and they need support for their families. I had one
Filipina, she’s joining one of my youth activities too because you know she needs something to
work through. Her mom is a gambler and an alcoholic.
An adolescent noted that Filipino parents worry about job related issues: “Some parents are
depressed because they lost a job. It’s hard to find a job now.” A faith leader also recognized that
parents are facing economic challenges and stated: “The times are difficult and economic
problems are cropping up, I would suspect that many Filipinos are undergoing a lot of mental
health problems but our culture does not sometimes permit us to be more open.”
A mental health provider stressed the importance of addressing parental depression:
A lot of times we see a child being referred for evaluation for ADHD (Attention Deficit
Hyperactivity Disorder) or other school problems and then we realize that this parent is really
depressed and needs their own intervention too. When I’m bringing the issue up, I try to frame it
as a response to stress, in that this is an incredibly difficult situation that you’ve been dealing
with for a long time now and it’s natural to expect that this is going to have an effect on you, and
the longer it has that effect, the more likely it is that it’ll be hard for you to continue your day to
day routine as effectively. And that can actually lead to changes in how you think and even in
your brain that can then make it harder to get yourself out of that place of feeling overwhelmed
and helpless, but it is possible to get out of there with appropriate help. Then we’ll also often
emphasize the importance of self-care for being an effective parent, so if, again if they’re still
kind of stuck in this sort of all-sacrifice mode….as long as you’re feeling this overwhelmed and
this depressed it’s going to make you less effective as a parent. If you’re really concerned about
the well-being of your children, you need to be on top of your game, so to speak…It’s like a
runner who’s reaching the end of the race and getting more and more tired, sometimes you just
don’t have enough to keep going on your own despite your best efforts. It’s not a moral
judgment, it’s not a criticism, and it’s just that this is the effect of all this taking its toll on you.
Discussion
The findings from this study fill an important gap by expanding understanding of the barriers
that need to be overcome when implementing mental health preventive interventions among
Filipinos. To our knowledge, this is the first study to explore the multiple perspectives of
Filipino adolescents, caregivers, providers, and advocates in order to identify recommendations
for behavioral health promotion among Filipino youth. In this study, participants indicated that
they preferred mental health prevention efforts in the Filipino community to include ways to
strengthen parent-child relationships, foster open communication, positive discipline, and discuss
limit setting and consequences. Providers suggested that such content could be delivered by
providing parenting support to families, such as evidence-based parenting programs. These
programs could prevent intergenerational conflict between Filipino adolescent youth and their
immigrant parents described in previous studies (Javier et al., 2010 and Chung et al., 2005) by
promoting effective parenting practices that can improve parent-child communication within
Filipino families. This in turn can lead to promotion of self-esteem and a strong ethnic identity as
Filipino youth go through the various stages of ethnic identity development as described by
Nadal (Nadal K.L., 2008).
In addition, participants suggested that parenting programs should target parents before their
children reach adolescence and offer them as prevention programs as opposed to for parents who
are having problems. This may help overcome the shame associated with seeking counseling or
mental health services. Prior to conducting these interviews, each ethnographic fieldworker will
be given training during the workshop on how to conduct an interview, including procedures for
establishing reciprocity and exchange of information, different types of questions, the use of
probes to elicit additional detail on a topic, and techniques for dealing with errors in informant’s
memory. Colonial mentality may partially explain why Filipinos are hesitant to admit they are
having problems raising their children in the U.S since they may want to save face in mainstream
U.S. society and not be identified as a high-risk population “in need”. Further, participants
suggested that prevention programs should also address parental well-being and parental stress.
This is especially critical given the significant mental health disparities and underutilization of
mental health services described among Filipino adults. For instance, alcoholism was described
as affecting Filipino parents in this study. This is consistent with previous literature describing
Filipinos turning to alcohol as a coping mechanism instead of seeking help for their mental
health problems (Nadal K.L., 2008).
Another important finding was that low participation in behavioral health services, such as
parenting programs among Filipinos may not solely be due to lack of access but also due to the
relevance of the setting in which they are offered. Offering mental health programs in faith
settings and specifically targeting Filipino parents may help overcome cultural mistrust that has
been described in the Filipino community (David E.J.R., 2010). These findings are consistent
with the findings from other studies of Filipino families (Chung P.J. et al., 2005; David E.J.R.,
2010; Javier J.R., Chamberlain L.J., et al., 2010) and non-Filipino families (Blank M.B.,
Mahmood M., Fox J.C., & Guterbock T., 2002; Brotman LM et al., 2011; Katz K.S. et al.,
2011; Kim E., Cain K.C., & Webster-Stratton C., 2008; Lawson E. & Young A., 2002).
This study applies the CDC’s model of community engagement by eliciting the varied
perspectives of consumers and stakeholders in order to bridge research evidence to practice
(Glasgow R.E., Green L.W., Taylor M.V., & Stange K.C., 2012). Several projects currently
ongoing in the U.S. have used community engagement to address disparities among Filipino
youth and adults and other minority populations in the area of mental health (Chung et al.,
2007; Javier et al., 2010; Kataoka et al., 2006; Ursua et al., 2013). This study’s results not only
helped answer “what” (i.e. evidence-based parenting interventions) needs to be implemented to
prevent mental health disparities among Filipino youth, but also provided insight regarding
“how” to optimally implement the evidence-based intervention (i.e. in faith settings) in this
population. For the Filipino community, culturally appropriate interventions for youth need to
involve the integration of faith and family. Without this integration, implementation may be
difficult.
These findings and recommendations for next steps were presented to participants and other
stakeholders addressing Filipino mental health in Los Angeles in May 2011. They were well-
received with one school-based leader noting: “I see a desire among my Filipino students to
build an emotional connection with their parents”. Further, as a result of this needs and resource
assessment activity, important collaborations were developed to actively address identified
priorities. Specifically, an academic-faith community collaboration formed in which grant
funding was secured to pilot-test the Incredible Years School-Age Basic Parent program (an
evidence-based parenting intervention) among Filipino parents as a faith-based prevention
program. Based on the data collected in this study, there are a number of evidence-based
programs that might be effective in improving parenting skills for this community. The
Incredible Years was selected because it was most consistent with participant views of the role of
parents in promoting the mental health and well-being of their children.

Limitations
The presented results should be interpreted with caution because of the following limitations.
First, the generalizability of these findings is limited by the snowball sampling technique and
nonrandom selection of study participants representing the three groups of stakeholders in the
Los Angeles area. Also, given our sample predominantly consists of single parent households,
and immigrant families residing in Historic Filipinotown, a middle-class working neighborhood,
our findings may not be generalizable to the general Filipino U.S. population. Future studies
using a random and more representative sample may obtain more accurate findings regarding the
recommendations for mental health prevention. Another study limitation was the lack of a formal
measure of cultural mistrust. Further study is needed to explore cultural mistrust as a barrier to
accessing mental health prevention programs among Filipino families. Finally, the findings were
limited to mental health issues known to be positively impacted by parent training. Other mental
health issues may need to also involve mental health professionals and other types of
practitioners.

Conclusions
The findings of this study have several implications for not only Filipino immigrant families but
also for mental health providers, educators training clinicians, and psychology researchers. By
understanding some of the salient influences of Filipino culture on behavioral health seeking,
mental health providers and educators can be better positioned to anticipate and teach trainees
about potential problem areas when working with Filipino families. Also, given the growing
emphasis to use evidence-based interventions, it is important for psychology researchers to
continue to engage Filipinos in research so that evidence-based practice evidence and outcomes
measures can be generated for this understudied minority population.
Finally, this study identified important strategies for mental health prevention that converge with
those identified in the literature on Filipino American youth and ethnic minority and immigrant
youth in general. The qualitative informant-based nature of the data provides insight into the
cultural dimensions of how these strategies can best be implemented. These finding are critical
because evidence-based parenting interventions remain one of the most effective strategies for
preventing adolescent behavioral problems (Institute of Medicine, 2009). Research eliciting
community perspectives that identify promising strategies to reach and retain underserved
populations in evidence-based interventions is critical to increasing the population impact of
these efficacious programs. Such strategies can shape future research and service efforts aimed at
eradicating mental health disparities seen between Filipino and non-Filipino youth.

Acknowledgments
This research was supported by the Children’s Hospital Los Angeles Department of Pediatrics
Academic Career Development Award, Southern California Clinical and Translational Science
Institute (NIH/NCRR/NCATS) Grant # KL2TR000131, and NIH Eunice Kennedy Shriver
National Institute of Child Health and Human Development Grant #1K23HD071942-01A1. The
authors wish to acknowledge Michele D. Kipke, Ph.D. for her mentorship and supervision,
Dennis Arguelles for providing community feedback, and all study participants for their
contributions.

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Mental health help seeking among Filipinos: a review of the literature
Antover P. Tuliao University of Nebraska-Lincoln, antover.tuliao@gmail.com

Published in Asia Pacific Journal of Counseling and Psychotherapy, 2014 Vol. 5, No. 2 © 2014 Taylor &
Francis Used by Permission. Mental health help seeking among Filipinos: a review of the literature
Antover P. Tuliao Department of Psychology, University of Nebraska – Lincoln, Lincoln, NE 68588-0308,
USA

Abstract: This study aims to provide a review of potential barriers to seeking mental health services
among Filipinos. Research on help-seeking behavior s among Filipinos living in the Philippines and other
countries (e.g., US, Canada, and Australia) suggest that mental health services in the Philippines are
inaccessible and monetarily prohibitive, and beliefs about the aetiology and nature of mental illness are
inconsistent with the medical model. Other cultural variables such as shame, stigma, and collectivist
beliefs also discourage Filipinos from seeking help from mental health professionals. Furthermore, these
variables could account for the preference for folk healers and lay networks in treating mental illnesses.
As such, cultural and economic factors need to be accounted for in conceptualizing Filipinos’ utilization
of mental health services. Implications and suggestions to aid practice were also discussed. Keywords:
Filipino; Philippines; help-seeking behavior; mental-health utilization; counseling and psychotherapy
Most of what we know about Filipino mental health help-seeking behavior is still limited, and mostly
extrapolations from the literature on Filipino Americans (e.g., AbeKim, Gong, & Takeuchi, 2004; Baello &
Mori, 2007; Gong, Gage, & Tacata, 2003), or Filipino Americans studied alongside other Asian Americans
(e.g., Li & Browne, 2000; Sorkin, Nguyen, & Ngo-Metzger, 2011). Extant literature suggests that Filipino
Americans utilize mental health services the least, compared to other Asian Americans (Abe-Kim et al.,
2007; Gong et al., 2003; Ying & Hu, 1994). For instance, in one epidemiological survey of 2285 Filipino
immigrants and Filipino Americans, only 3% sought help from any mental health professional for their
emotional problems or emotional distress (Abe-Kim et al., 2004). In another study utilizing the same
sample, Gong and colleagues report that 17% of Filipino Americans and Filipino immigrants sought help
from lay networks and 4% from folk healers. Although prior research has been conducted using a
multicultural lens (e.g., Abe-Kim et al., 2004; David, 2010; Gong et al., 2003), some barriers to mental
health help seeking may not be applicable to Filipinos living in the Philippines, such as cultural mistrust,
acculturation, limited English proficiency or the lack of Filipino-proficient service providers (David, 2010;
U.S. Department of Health and Human Services, 2001). Furthermore, conclusions drawn from studies of
Asian Americans (e.g., Leong, 1986; Leong & Lau, 2001) presume that Asians are a homogenous
population, which is not the case (Kuo, 1984). 1 digitalcommons.unl.edu 2 Tuliao, Journal of Asia Pacific
Journal of Counselling and Psychotherapy, 2014 Although limited, there is burgeoning evidence
indicating a general reluctance to seek professional help for mental health problems among Filipinos
living in the Philippines. For instance, Hechanova and colleagues (Hechanova, Tuliao, & Ang, 2011;
Hechanova, Tuliao, Teh, Alianan, & Acosta, 2013) concluded that intent to seek online counseling among
Filipino overseas migrant workers was low. In a survey of 359 Filipino college students in the Philippines,
only 22% in their lifetime sought professional help for an academic or non-academic issue, and there
was a significantly higher preference to seek help from friends and family members than from
professional counselors and psychotherapists (Bello, Pinson, & Tuliao, 2013; Bunagan, Tuliao, &
Velasquez, 2011). The underutilization of mental health services, however, cannot be attributed to lower
rates of distress and psychopathology. Among Filipinos, the prevalence of mental disorder is 88 cases
per 100,000, reaching up to 133 cases per 100,000 in some areas (Department of Health [DOH], 2005).
Another estimate suggests a mental disorder lifetime prevalence rate of 32% among Filipinos living in
the capital, Manila (Pabellon, 2012). This paper aims to provide an exposition of the possible reasons for
Filipinos’ underutilization of mental health services using contextual, cultural, and psychological lenses.
First, a very brief demographic and historical overview of the Philippines will be provided in the hope
that this will provide an adequate context to the readers. Second, the possible role of the current state
of mental health services regarding the reluctance to seek professional help will be discussed. Finally,
this paper will explore the role of cultural factors, such as lay or folk conceptualization of mental illness,
stigma and loss of face, and norms regarding interpersonal relationships. For the purposes of this paper,
Filipinos refers to Filipinos living in the Philippines. However, due to a general low psychological research
output in the Philippines (Montiel & Teh, 2004), research involving Filipino Americans and Filipinos living
in other countries will be referred to in the absence of indigenous research. Philippines: a brief overview
Sanchez and Gaw (2007) argues that the Philippine culture is an amalgamation of different cultures. As
an archipelago of 7107 islands located in Southeast Asia (Central Intelligence Agency [CIA], 2011), the
Philippine culture is influenced by the surrounding Indo-Malay, Chinese, and Islamic cultures (Majul,
1966; Miclat, 2000). Prior to the Spanish colonization in the sixteenth century, the Philippines comprised
autonomous principalities and kingdoms (Bernad, 1971; de Torres, 2002). This precolonial political
system, some authors argue, influenced the Filipino tendency towards regionalism (Bernad, 1971; de
Torres, 2002). In addition, this precolonial political system may have also influenced the heterogeneity in
language, with the Philippines having eight major dialects (Filipino and English are the main languages;
CIA, 2011). Three centuries of Spanish colonization also significantly influenced Philippine culture,
particularly in religion. Currently, Roman Catholicism is the predominant religion (83%), followed by
Islam (5%), and the rest comprises different Christian denominations (CIA, 2011). Religious affiliations
notwithstanding, animistic, and indigenous beliefs are still practiced, such as in the folk healing practices
(Tan, 2008). After Spain, the US colonization also left an indelible mark on Philippine culture, education,
and political system. Currently, there are an estimated 94 million Filipinos in the Philippines and an
estimated 8 million employed in different parts of the world as short-term overseas migrant workers
(Philippine Overseas Employment Agency, 2008; World Health Organization [WHO], 2011). Almost half
(49%) of the population is reported to be living in urban areas, and Mental health help seeking among
Filipinos 3 gender distributions are also relatively equal (WHO, 2011). The majority of the population is
between the ages of 15 and 65 (62%), and 34% are below 15. The literacy rates are 84% for males and
89% for females (WHO, 2011), and poverty rate ranges from 22% (National Statistical Coordination
Board, 2013) to 61% (National Statistics Office [NSO], 2010), depending on the definition. Current
mental health services Before possible predictors of mental health service underutilization can be
addressed, it is important to first discuss if there are sufficient mental health professionals and services
in the Philippines. In other words, underutilization of mental health services could be a function of a lack
of professionals and services rather than a general reluctance to seek these services. In the Philippines,
four general professions are legally recognized to provide mental health services: guidance and
counseling practitioners (Guidance and Counseling Act of 2004); psychologists (Philippine Psychology Act
of 2009); social workers (Republic Act No. 4373 (1965)); and those within the umbrella of the medical
profession. Under the Guidance and Counseling Act, an average of 134 professionals was licensed to
practice yearly since 2008 to 2012 (Philippine Regulatory Commission, n.d.). At the time of writing this
paper, the licensure examination of psychologists and psychometricians has not yet started. However,
according to the roster of specialist psychologist of the Psychological Association of the Philippines (the
Philippine counterpart of the American Psychological Association), there are 98 assessment
psychologists, 114 clinical psychologists, 82 counseling psychologists, and 24 developmental
psychologists that are presumed able to provide psychological assessment and intervention. As a result
of the nascent nature of the licensure examination for both guidance and counseling and psychology
laws, no information is available on the ratio of these mental health professionals vis-à-vis the Philippine
population. No research is available on how these recent changes have affected attitudes towards the
utilization of mental health services. No information is readily available for other mental health
professionals, such as addiction counselor sand pastoral counselors. Better estimates are available for
those within the ambit of the medical profession. Research suggest that there are 0.40 psychiatrists,
0.40 psychiatric nurses, 0.17 medical doctors not specialized psychiatry, 0.14 psychologists, 0.08 social
workers, and 0.08 occupational therapists per 100,000 general population (Jacob et al., 2007; WHO,
2006). As for inpatient units, WHO (2006) reports 19 community-based psychiatric inpatient units, which
accommodate 1.58 beds per 100,000, and 15 community residential facilities that have 0.61 beds/ place
per 100,000. Jacob and colleagues (2007), however, report a much lower estimate of 0.09 mental health
beds per 100,000. As for outpatient units, there are 46 outpatient mental health facilities which cater for
124.3 users per 100,000, and four day-treatment facilities which treat 4.42 users per 100,000. Are there
sufficient mental health professionals and facilities? If the United States Department of Health and
Human Services’ (n.d.) criteria were to be used, then the Philippines have a shortage of mental health
professionals. According to the criteria, an area should have at least (a) a core mental health
professional to population ratio of 16.67:100,000 and a psychiatrist to population ratio of 5:100,000, or
(b) a core mental health professional to population ratio of 11.11:100,000, or (c) a psychiatrist to
population ratio of 3.33:100,000. Making matters worse is the current trend of mental health
professionals leaving to work in other countries (WHO, 2006). Facilities are also severely lacking, and
available only in urban centers (Conde, 2004; WHO, 2006). The largest government psychiatric facility lo-
4 Tuliao, Journal of Asia Pacific Journal of Counselling and Psychotherapy, 2014 cated in the capital city,
The National Centre for Mental Health, holds 67% of the psychiatric beds in the country, and the rest of
the mental health facilities are perpetually overcrowded, and effectively nonfunctional due to
manpower and budgetary constraints (Conde, 2004). Medical doctors (one for every 80,000 Filipino) are
also scarce compared to traditional healers (one for every 300 Filipinos), which could perpetuate the
Filipino’s reliance on folk medicine (WHO & DOH, 2012). As for school counsellors, the reported
counselor–client ratio was 1:800–1000 (Villar, 2000). Economic issues also need to be considered. For
instance, the cost of counseling in the Philippines ranges from 500 to 2000 Philippine pesos (Php), or
USD 12–USD 50 per session (Tuason, Galang-Fernandez, Catipon, Trivino-Dey, & Arellano-Carandang,
2012). When juxtaposed with the minimum daily wage of Php 456 or USD10 (National Wages and
Productivity Commission, 2014), and 61% of the population living on or less than USD 2 a day (NSO,
2010), the cost of seeking counseling from a trained mental health professional may be prohibitive.
Since alternative medicine is much cheaper (e.g., USD 0.44 for acupuncture), it is understandable that
50% to 70% of the population use traditional and complementary medicine (Lagaya, 2005; WHO & DOH,
2012). Conceptualizations of mental illness One way to narrow the discrepancies in utilization of mental
health services is through a better understanding of the conceptualizations of mental illness (Sue,
Cheng, Saad, & Chu, 2012). This is made even more salient given that 70% to 90% of all healthrelated
decisions are made outside of the formal health sector, which includes families, social networks, and
community, both in the Western and non-Western settings (Jovchelovitch & Gervais, 1999; Kleinman,
1986). However, Philippine folk conceptualizations of illnesses do not differentiate between physical and
mental disorders, and a review of how both medical and psychological illnesses are framed suggests that
Filipinos conceptualize disorders differently from the medical model (Araneta, 1993; Tan, 1987, 2008).
Lay conceptualizations of physical and psychological disorders have implications for help seeking for
psychological disorders, at least on the issue of the preference for indigenous or folk healers. In one
early study by Shakman (1969), indigenous and folk healers were sought for ‘disturbed behavior ’, as
well as for somatic complaints that have no verified underlying medical causes. The importance of bodily
symptoms without medical causes is made even more salient given that different cultural groups
manifest psychological symptoms as somatic complaints (e.g., Tsai & Chentsova-Dutton, 2002).
Moreover, somatic symptoms are more emphasized than the affective component of depression among
non-Western cultures (Tsai & Chentsova-Dutton, 2002). For a thorough discussion on the Filipino
traditional conceptualization of illnesses, the readers are encouraged to consult Michael Tan’s (2008)
book ‘Revisiting Usog, Pasma, Kulam’. One core theme in the conceptualization of physical and
psychological disorders implicates the role of supernatural beings such as gods, spirits, and deities, or
individuals with supernatural powers such as mangkukulam (loosely translated as witches). For instance,
Edman and Kameoka’s (1997) study reveals that educated and less educated Filipino women attribute
illnesses to spiritual causes (God, chance, witchcraft and sorcery, and spirits) compared to their
American counterparts. In defining dissociative disorders, Filipinos were more likely to define the
symptoms as a product of spirit possession, rather than that of a psychological disorder (Gingrich, 2006).
Tan Mental health help seeking among Filipinos 5 (2008) also opines that some psychological symptoms
or disorders are thought of by Filipinos as a form of spirit possession or as a result of having offended
the spirits. Another core theme in conceptualizing physical and psychological disorders involves soul
loss, lack of balance, and pollution/contagion (Araneta, 1993; Tan, 2008). For instance, chronically ill
recently immigrated elderly Filipino Americans believe that the work-life imbalance, too much worrying,
overworking, and increased stress cause illnesses (Becker, 2003). In addition, rapid shifts from a warm to
cold environment cause illnesses, and health is maintained by keeping the body in a warm condition.
Cholesterol and other toxins are thought to pollute the body, and perspiration is one way to flush out
these. Behavior s such as indifference, withdrawal, irrationality, and nightmares (bangungot) are
believed to be a result of ‘soul loss’ (Araneta, 1993). Relationship problems are purported to also cause
illnesses. For instance, Filipino women living in Australia believe that the primary cause of depression is
the lack of social support (Thompson, Manderson, Woelz-Stirling, Cahill, & Kelaher, 2002). This prompts
the attitude that mental health professionals are ‘not helpful ... because a friend could fulfill the same
role’ (Thompson et al., 2002, p. 685). Emotional problems are considered transitory and relationship-
related, and can be solved by talking to friends, family members, or trusted community members
(Hechanova et al., 2011). Aside from psychological issues, relationship problems can also cause physical
illness (Edman & Kameoka, 1997). Other lay conceptualizations emphasize personal responsibility of the
person with the illness. Severe mental problems, for example, are believed to be caused by a ‘softness’
of character and individual attributes (Thompson et al., 2002). Furthermore, being able to cope with
one’s emotional problems is also valued, and perceived to be one’s own responsibility (Thompson et al.,
2002). Some psychological and physical illnesses are also thought to be an evil act, or as a result of
engaging in one. In studying the media discourse of substance abuse, Filipino tabloid and broadsheets
mostly represented those with the disorder as criminals, murderers, rapists, and engaging in sexual
deviations (Tuliao, 2009). Only a minority of newspaper entries represented those with substance use
disorders as mentally ill, however these representations were placed with suicide, self-mutilation,
hallucinations, and delusions. Tan (2008) also documents some Filipino beliefs suggesting that physical
and psychological illnesses are caused by sumpa (curse) brought about by a violation of strict family
values, or are caused by gaba, or a curse or retribution from God. There are also indications that
Filipinos may consider some behavior s ‘normal’ that would otherwise be considered a symptom of
psychological illness based on the medical model. In defining dissociative disorders, Filipinos were more
likely to define symptoms as a product of spirit possession, rather than a product of a psychological
disorder (Gingrich, 2006). Having large gaps in one’s memory, hearing voices in one’s head, having
identity confusion and alteration were also thought to be normal. Gingrich also argues that, given how
dissociative disorders are conceptualized, the constellation of psychological disorders may be attributed
to spirit possession or considered under the general umbrella of baliw (crazy). The type of traditional
and complementary medicine that Filipinos typically resort to complements the lay conceptualizations
of physical and psychological disorders. For spirit possessions and illnesses are believed to be caused by
malevolent spirits, so that a combination of prayers, herbs and medicinal plants are used by shamans,
herb doctors (arbolarios or herbalarios), and ‘white’ witches (Araneta, 1993) to overcome the problems.
Massage (similar to acupressure or reflexology) and ‘magnetic healing’ (where the healer’s hands are
placed on the affected area, and the healer prays or meditates) are used to restore 6 Tuliao, Journal of
Asia Pacific Journal of Counselling and Psychotherapy, 2014 the normal flow and balance of life-force
(Araneta, 1993; Tan, 2008). To relieve pain, reduce anxiety, improve state of mind, herbal medicines and
massage are utilized by bonesetters (manghihilot) and arbolarios (Araneta, 1993; Lagaya, 2005). These
are some of the folk healing practice that Filipinos resort to, and current traditional and complementary
medicine being utilized today is observed to be an amalgamation of indigenous practices which date
from before Spanish colonization, with some influences from Ayurvedic and Chinese traditional
medicine (Lagaya, 2005). The argument towards the need to understand conceptualizations of mental
illness is straightforward: the type of help sought will depend on how the illness is defined and what the
etiological attributions are. Unfortunately, very little research exists on Filipinos’ conceptualization and
expression of mental illness or psychological distress. Other areas that need more research are on the
domain of the cultural expressions of psychopathology and culture-bound illnesses (López & Guarnaccia,
2000). As long as there is a disconnection between the etiological beliefs of psychological disorders and
the type of services that mental health practitioners provide, then we should expect a continued
underutilization of mental health services and a continued preference for folk healers and social
networks to alleviate psychological problems (Furnham & Hayward, 1997; Kulhara, Avasthi, & Sharma,
2000; Lee, 2007; Urdaneta, Saldana, & Winkler, 1995). Public and private stigma, hiya, and loss of face
The unique construal of mental illness or psychological difficulties could lead to stigmatization, which
subsequently discourages individuals from seeking mental health services. Stigma and its detrimental
effect on mental health help-seeking behavior s has been documented in developed countries (Alvidrez,
Snowden, & Kaiser, 2008; Cooper, Corrigan, & Watson, 2003; Corrigan, 2004) and among Asian cultures
(Fogel & Ford, 2005; Miville & Constantine, 2007; Shea & Yeh, 2008). Culture also plays a big role in
shaping attitudes and social interactions with individuals with mental illness, as well as in its treatment
(Abdullah & Brown, 2011). The public’s discriminatory response, also known as public stigma (Corrigan &
Kleinlein, 2005), is then internalized (private stigma), resulting in diminished self-worth and self-efficacy,
shame, low self-esteem, and subsequent reluctance to seek treatment (Corrigan, 2004). Among
Filipinos, studies show that private stigma is negatively correlated with the intention to seek
professional help, and mediates the relationship between public stigma and attitudes towards seeking
professional help (Garabiles, Tuliao, & Velasquez, 2011; Tuliao & Velasquez, in press). Although
stigmatization and its effects on mental health help-seeking behavior s are not unique to Filipinos
(Abdullah & Brown, 2011; Lauber & Rössler, 2007), hiya could be a potential barrier or a compounding
problem to seeking mental health services. Hiya has been loosely translated by some scholars as
‘shame’. However, Pe-Pua and ProtacioMarcelino (2000) would argue that, depending on prefixes and
suffixes, the meaning can range from shy (mahiyain), embarrassment or awkwardness (napahiya), to a
sense of propriety (kahihiyan). For the purposes of this paper’s topic, the most apt translation would be
embarrassment and a sense of propriety. As an experience beyond embarrassment, hiya is a painful
emotion arising from real or imagined transgressions of social norms or authority figures, and its
avoidance is paramount in social interactions (Bulatao, 1964). Hence, if having emotional distress or
psychological problems are frowned upon, then divulging these issues to the public are to be avoided at
all costs. Mental health help seeking among Filipinos 7 Although the concrete role of hiya on mental
health help-seeking behavior has not yet been studied, loss of face, an arguably related construct, has
been previously researched (Abe-Kim et al., 2004; David, 2010; Gong et al., 2003). Loss of face has been
defined as the threat or loss of one’s social integrity, especially as it relates to social relationships and
one’s social standing, and oftentimes measured using the Loss of Face Scale (Zane & Yeh, 2002). Hence,
preserving or maintaining face is a tremendous motivational factor that influences individuals to abide
by social mores and avoid others’ negative impression. Whereas some would consider face as a
universal construct, others assume that it is more salient among Asians (Lin & Yamaguchi, 2011). Results
in loss of face, however, are inconsistent, with some suggest that it is positively associated with the
intent to seek mental health treatment (Yakunina & Weigold, 2011), whereas others suggest the
opposite (Leong, Wagner, & Kim, 1995). The discrepancy could be a product of the ethnic heterogeneity
of the participants in the study. Among Filipino Americans, research suggests that loss of face was
negatively associated with past utilization and propensity to seek help from mental health professionals,
positively associated with willingness to seek help from lay networks, and not related to help seeking
from general practitioners and folk healers (David, 2010; Gong et al., 2003). However, among Filipinos,
loss of face was positively associated with intent to seek face-to-face and online counseling (Bello et al.,
2013). On the other hand, relationships between loss of face and help-seeking-related variables are
similar between Filipinos and Filipino Americans. Studies suggest that loss of face was negatively
associated with indifference to stigma and psychological openness among Filipino Americans (David,
2010; Gong et al., 2003). Among Filipinos, loss of face was negatively associated with attitude towards
counseling, and positively associated with perceived stigma for seeking help and receiving psychological
help (Bello et al., 2013). Qualitative studies suggest that loss of face or shame may be implicated in the
Filipinos’ reluctance to seek professional help. For Filipino women living in Australia, Thompson and
colleagues (2002) show that fear of being labeled as ‘crazy’ and to avoid tarnishing the family’s
reputation was a barrier to seeking professional help (Thompson et al., 2002). In comparison to face-to-
face counseling, some Filipinos preferred online counseling because of the anonymity it provided which
lessened the effects of hiya (Hechanova et al., 2011). Preference for lay networks and mental health
professional as ibang tao Filipinos prefer to seek help from their lay networks for their emotional
problems rather than from mental health professionals (Abe-Kim et al., 2004; Bunagan et al., 2011;
Gong et al., 2003; Hechanova et al., 2011; Thompson et al., 2002), and the Filipino core value of kapwa
could elucidate this phenomenon. Kapwa emphasizes treating others as kapwa or a fellow human being,
a tenet that goes beyond mere conformity, avoidance of conflict, or the simplistic Individualism–
Collectivism dichotomy (Pe-Pua & Protacio-Marcelino, 2000). Although the goal is to treat others as a
fellow human being, the dictates of social interaction vary according to whether one is categorized as
Ibang Tao (outsider) or Hindi Ibang Tao (one-of-us). Social interaction among those considered as an
outsider could vary from civility (pakikitungo), participating (pakikilahok), to being in conformity with
(pakikibagay) or going along with (pakikisama). On the other hand, interactions with those considered
‘one-of-us’ can vary from rapport/acceptance (pakikipagpalagayangloob) to being one with (pakikiisa). 8
Tuliao, Journal of Asia Pacific Journal of Counselling and Psychotherapy, 2014 Evidence suggests that
interaction with health professionals varies according to how they are categorized by the patient (Pasco,
Morse, & Olson, 2004). Filipino Canadians were reticent and were less likely to reveal their emotions to
nurses they considered ibang tao. Furthermore, communication between patient and health
professional was done through a go-between (tagapamagitan) especially when the professional was
ibang tao. Hence, it is not surprising that openness to counseling is mediated by family and friends
(Tuason et al., 2012). In interacting with an ibang tao health professional, Filipinos are formal, polite,
and cordial, and may express agreement to medical advice, but may not necessarily comply. As the
interaction progresses from ibang tao to hindi ibang tao, Filipino patients are more likely to articulate
their emotions and concerns directly and entrust themselves to the care of the medical professionals
(Pasco et al., 2004). Pasco and colleagues (2004) outline several characteristics that would help the
medical professional transition from being ibang tao to hindi ibang tao. As pakikipagkapwa-tao or
pakikiisa (oneness) is valued among Filipinos, it is similarly expected from interactions with others in
order to be considered ‘one-of-us’. Responding immediately and being sensitive to the needs of the
patient, as well as avoiding being rude or conceited fosters trust among Filipinos. Indeed, marunong
makiramdam (sensitivity to other’s needs), and the concomitant skill pakikiramdam (shared inner
perception), is another valued trait among Filipinos (Pe-Pua & Protacio-Marcelino, 2000). Filipinos have
a propensity for indirect communication, and being sensitive to non-verbal cues, as well as being able to
‘feel for another’, is entrenched in socialization practices. Apart from being sensitive to non-verbal cues,
health professionals can communicate care through non-verbal behavior s and voice intonation, which
would subsequently foster trust among patients. Other correlates of mental health help-seeking
behavior Apart from those mentioned, prior studies also uncovered other variables that are associated
with mental health help-seeking behaviors. Problem severity and attitudes supportive of counseling
were associated with willingness to seek professional help among a sample of Filipino college students
(Bunagan et al., 2011; Gong et al., 2003; Tuliao & Velasquez, in press). Ease in operating the system and
the presence of computers and access to internet was associated with higher intent to seek online
counseling among migrant workers, even after accounting for problem severity (Hechanova et al., 2013).
Gender’s effect on help-seeking behavior has had mixed results. Studies on Filipino Americans suggest
no gender differences in mental health help-seeking behavior (Baello & Mori, 2007; Gong et al., 2003),
which contradicts studies suggesting that men are more reluctant to seek help than women (Addis &
Mahalik, 2003). Findings were similar for Filipinos, i.e., there were no significant gender difference
between attitudes towards professional help seeking and intent to seek professional help (Bunagan et
al., 2011). It is important to emphasize though that both genders were equally reluctant to seek
professional help for psychological difficulties. Furthermore, the study by Bunagan et al. (2011) was a
bivariate correlational analysis. Hence, multivariate studies are needed to fully clarify the role of gender.
For seeking help from lay networks, women are more likely to seek help from lay networks compared to
men (Bunagan et al., 2011), consistent with the results of Gong and colleagues (2003). Although gender
norms dictate that men should be strong and not show emotional vulnerability (Aguiling-Dalisay et al.,
1995), these gender imperatives seem to only influence help seeking from lay networks. It is plausible to
posit that other variables are more influential in predicting help seeking from professional mental health
professionals other than gender. Mental health help seeking among Filipinos 9 Summary and
recommendations for future research This paper aimed to uncover possible hypotheses for Filipino’s
underutilization of mental health services. From an economic and contextual perspective, Filipinos may
not be accessing mental health services because it is inaccessible and prohibitive. As previously
discussed, most of the mental health professionals and facilities are located in the urban areas and in
the capital Manila, and the ratio of professional to population is below the minimum standards (WHO).
Professionalization of counselors and psychologists is also in its early stages. This increases the Filipinos’
reliance on traditional and folk healers, which are more accessible and cheaper than mental health
professionals. Furthermore, lack of contact with professionals could further alienate people from the
mental health service providers. However, no research was available regarding the impact of the
inaccessibility and the expense on the willingness to seek mental health services among Filipinos. This
area can be studied from an economical, sociological, and psychological perspective. Other cultural
factors were also considered. First, conceptualizations, definitions, and expressions of psychological
distress were investigated. The review of the literature suggests that Filipinos may be conceptualizing
mental illness and psychological distress differently from the mainstream medical model. Beliefs about
the aetiology of illnesses are influenced by cultural beliefs regarding spirits and humoral changes, which
could subsequently influence Filipinos to seek treatment with traditional and folk healers whose
modality of treatment is concordant with their beliefs. Similarly, when the psychological distress is
believed to be social in nature, Filipinos resort to lay networks for support. However, very little empirical
research has been done on how Filipinos frame mental illness and psychological disturbance, and how it
influences their choice of treatment provider. Furthermore, there is a paucity of research on how
Filipinos manifest symptoms for psychological disorders. Second, hiya and loss of face are culture-
specific variables that are hypothesized to influence mental health service utilization. Stigmatization of
the mentally ill is a dilemma found in several cultures that serve as barriers in seeking psychological
treatment. The way culture shapes attitudes and behavior s towards the mentally ill (public stigma) gets
internalized, which subsequently results in low self-efficacy, shame, and reluctance to seek treatment.
Hiya and loss of face are cultural values that aim to preserve one’s integrity and to avoid real or
imagined social transgressions. Hiya and loss of face, therefore, can hypothetically further compound
reluctance to seek psychological help especially when the culture deems mental illness as an aberration.
There are, however, areas and questions that need to be resolved. The precise relationship between
hiya and loss of face is still unknown, and the specific underlying mechanism on how these influence
willingness to seek psychological treatment, and from whom, is still undetermined. Third, culturally
specific social interaction norms could influence who Filipinos seek for treatment of psychological
distress. Using the Ibang Tao–Hindi Ibang Tao dichotomy, we can see that there are social norms that
are not conducive to the requirements of counseling and psychotherapy. For Filipinos to clearly
articulate their problems and emotions, the mental health professional needs to be considered as Hindi
Ibang Tao, and future research can focus on how to transition clients from thinking about the
professional away from being Ibang Tao. Finally, other variables previously found to be associated with
psychological helpseeking behavior need to be replicated in a Filipino sample to assure generalizability
of findings. As previously mentioned, research on Filipino Americans, Filipino Canadians, Filipino 10
Tuliao, Journal of Asia Pacific Journal of Counselling and Psychotherapy, 2014 Australians, and Filipino
emigrants’ help-seeking behavior are coloured by issues of acculturation, racism, and social injustice,
some of which may not be applicable to Filipinos. Furthermore, research among Filipinos can further
inform multicultural research in other countries, helping them further delineate which variables are
culturally influenced versus those which are influenced by migration. Funding This research received no
specific grant from any funding agency in the public, commercial, or not-for-profit sectors. Notes on
contributors Antover P. Tuliao obtained his Masters in Counseling Psychology at the Ateneo De Manila
University, Philippines, and is currently a doctoral student at the University of Nebraska – Lincoln Clinical
Psychology Program. His research interests include help-seeking behavior s among Filipinos, and the
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https://digitalcommons.unl.edu/cgi/viewcontent.cgi?
referer=https://www.google.com/&httpsredir=1&article=1792&context=psychfacpub
 Factors Associated with Depressive Symptoms
among Filipino University Students
 Romeo B. Lee ,
 Madelene Sta. Maria,
 Susana Estanislao,
 Cristina Rodriguez

 Published: November 6, 2013

 https://doi.org/10.1371/journal.pone.0079825

Abstract
Depression can be prevented if its symptoms are addressed early and effectively. Prevention against depression
among university students is rare in the Philippines, but is urgent because of the rising rates of suicide among the
group. Evidence is needed to systematically identify and assist students with higher levels of depressive symptoms.
We carried out a survey to determine the social and demographic factors associated with higher levels of depressive
symptoms among 2,436 Filipino university students. The University Students Depression Inventory with measures
on lethargy, cognition-emotion, and academic motivation, was used. Six of the 11 factors analyzed were found to be
statistically significantly associated with more intense levels of depressive symptoms. These factors were: frequency
of smoking, frequency of drinking, not living with biological parents, dissatisfaction with one’s financial condition,
level of closeness with parents, and level of closeness with peers. Sex, age category, course category, year level and
religion were not significantly related. In identifying students with greater risk for depression, characteristics related
to lifestyle, financial condition, parents and peers are crucial. There is a need to carry out more surveys to develop
the pool of local knowledge on student depression.

Citation: Lee RB, Maria MS, Estanislao S, Rodriguez C (2013) Factors Associated with Depressive Symptoms
among Filipino University Students. PLoS ONE 8(11): e79825. https://doi.org/10.1371/journal.pone.0079825
Editor: Hamid Reza Baradaran, Iran University of Medical Sciences, Islamic Republic of Iran
Received: June 9, 2013; Accepted: October 4, 2013; Published: November 6, 2013
Copyright: © 2013 Lee et al. This is an open-access article distributed under the terms of the Creative Commons
Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the
original author and source are credited.
Funding: The authors have no support or funding to report. The study was carried out as part of the community
engagement activities of the authors.
Competing interests: The authors have declared that no competing interests exist.

Introduction
Depression is a major source of the burden of disease throughout the world [1]. In much of the developing
world, however, depression is largely unexplored as a research topic. A social mapping revealed that,
even though the mental disorder has been recognized as a research priority, only a sparse number of
relevant studies have been carried out in low- and middle-income countries [2]. Roughly 60% of these
countries have contributed fewer than five articles to the international mental health indexed literature [2].
Strategic evidence is needed in order to prevent the occurrence of depression, including its pernicious
effects and prohibitive treatment cost.

Prevention of depression, particularly among university students in developing countries, is urgent. With
their large student populations and the developmental propensity of students for depression [3], the
burden of the mental disorder is heavy on this demographic sector [4–6]. Preventive efforts in the
developing world, however, are rare. Consistent with observations elsewhere [7,8], depression is widely
perceived in this part of the world as innocuous and as part and parcel of normal adolescent
development. Students with the mental disorder are not only suffering in silence, but are also placing their
academic and future life goals in peril. Depression can be averted if students with depressive symptoms,
comprising not only physical but also non-physical conditions (e.g., cognition-emotion and motivation) [ 9],
are promptly and properly identified and helped.

Extant studies suggest that students with higher levels of symptoms tend to be women [10,11], older and
in their senior year [5], and Catholics and/or Jews [12,13]. Moreover, research indicates that highly
symptomatic students do not reside with their parents in one household [14], and are smoking [15] and
drinking alcohol [16], and belong to the low-income bracket [6]. Furthermore, students with more severe
levels of depressive symptoms have lower levels of closeness with their parents or with friends [7].

The context of the present study

The Philippines has a total population of 92.3 million that is very young (median age: 23) and growing at 1.9%
annually. In 2009-2010, 2.8 million university students were enrolled in the country’s 2,247 higher education
institutions. Of every 10 Filipino students, 6 and 4 are enrolled in private and public universities, respectively. Of
these students, 26% are enrolled in business, 16% in medicine and allied programs, and 13% each are in
engineering, information science and education [17]. In contrast to their counterparts throughout most of the world,
Filipino students commence their university education at the age of 15 or 16 years.

Filipinos place a high premium on formal education; a university degree is strongly regarded as a primary
requirement for social and economic mobility. In the context of the collective aspirations of Filipinos to go abroad
for lucrative employments, the need for university education is even more compelling. Individual students are thus
pressured to excel or complete a degree, lest they bring dishonor to their family and friends, and endanger their
employment and life prospects. In this respect, academic-related matters are salient issues for individual students
and in their relationships and conflicts with parents; these, too, can induce higher levels of depressive symptoms in
students.

We carried out this research as part of our community engagement activities to help in the prevention of mental
disorders, and subsequently, of suicide among Filipino university students. The connection between depression and
suicide is well-established [18]. The spate of suicide events among local students had served as the impetus to
conceive and implement this study. There is paucity of data on university student depressive symptomatology in the
Philippines, and in the absence of published relevant articles in indexed journals, little is understood about
depressive symptoms among Filipino university students at the international level. This survey examined the social
and demographic factors associated with higher levels of depressive symptoms among Filipino university students.
The University Student Depression Inventory (USDI), a newly-developed and psychometrically sound scale with
measures on academic motivation in addition to lethargy and cognition-emotion, was used.
Methods
Participants

Data were derived from a complete enumeration survey undertaken in 2012 covering all 67 undergraduate classes in
general social sciences (e.g., introductory sociology) at a large private university (total student population: >16,000)
in Manila, the Philippines. Roughly half of the 67 classes were surveyed in the middle of Term 1 and the other half
in the middle of Term 2. A total of 2,591 Filipino students anonymously completed the 10-page self-accomplished
questionnaire. Only the questionnaires of 2,436 students were considered for the purpose of this report (126
questionnaires of international students were excluded and 29 questionnaires with at least 10 unanswered items were
invalidated). Our sample represents about 15% of the university’s total undergraduate student population.

Measures

We utilized the USDI to measure depressive symptoms as a continuous variable. The USDI, developed by Khawaja
& Kelly [9], measures the academic motivational aspect of depressive symptoms in addition to physical and
cognitive-emotive dimensions. The USDI has 3 sub-scales having a total of 30 statements: lethargy (9 statements on
lethargy, concentration difficulties and task performance); cognitive-emotional (14 statements on suicide ideation,
worthlessness, emotional emptiness and sadness); and academic motivation (7 statements on class attendance and
motivation to study) (Table 1). Statements have score-bearing response options ranging from “none at all” (1) to “all
the time” (5). The USDI has a high level of internal consistency (Cronbach α=0.95) [9].

Parents
1. I like spending time with my parents.
2. My parent/s show/s how much she/she/they love me.
3. I feel good being with my parents.
4. My parent/s does/do not really care about me.*
5. I disclose my private concerns to my parent/s.
6. I am not happy when I spend time with my parent/s.*
7. I think my parent/s is/are the best in the world.
8. I wish my parent/s paid more attention to me.*
Peers
1. I feel happy when I am with my friends.
2. I would rather be alone than spend time with my friends.*
3. My friends show me their support.
4. My friends do not treat me well.*
5. I wish I had more supportive friends.*
6. I am satisfied with the friendships I develop in school.
7. I like spending time with my friends.
8. I do not enjoy spending time with my friends.*
9. I am happiest when I am with my friends.
Depressive symptoms
A. Lethargy
1. I am more tired than I used to be.
2. I do not have the energy to study at my usual level.
3. My energy is low.
4. I find it hard to concentrate.
5. I don't feel rested even after sleeping.
 Parents
6. I am overwhelmed by the challenges I encounter in my studies.
7. My mood affects my ability to carry out assigned tasks.
8. Daily tasks take me longer than they used to.
9. My study is disrupted by distracting thoughts.
B. Cognitive/emotional
10. I wonder whether life is worth living.
11. I feel worthless.
12. I have thought about killing myself.
13. No one cares about me.
14. I feel emotionally empty.
15. I feel sad.
16. I worry I will not amount to anything.
17. The activities I used to enjoy no longer interest me.
18. I feel like I cannot control my emotions.
19. I spend more time alone than I used to.
20. I feel disappointed in myself.
21. I feel withdrawn when I'm around with others.
22. I do not cope well.
23. I think most people are better than me.
Academic motivation
24. I do not have any desire to go to my classes.
25. I do not attend classes as much as I used to.
26. I don't feel motivated to study.
27. Going to university is pointless.
28. I have trouble starting assignments.
29. I do not find study as interesting as I used to.
30. I have trouble completing study tasks.
*Reverse coded
Table 1. Statements used for measuring levels of closeness with parents and with peers, and depressive
symptoms.

The socio-demographic characteristics include sex, age category, course category, year level, religion, frequency of
smoking, frequency of drinking, living/not living with both biological parents, level of satisfaction with one’s
financial condition, level of closeness with parents, and level of closeness with peers. The last 2 variables were
measured using a series of 8 statements on parents and 9 statements on peers. The statements were drawn from
published studies on parental and peer relationships among adolescents [7,19]. Each series had 4 score-bearing
response options: definitely not true (1), mostly not true (2), mostly true (3), and definitely true (4) (Table 1).

Ethical standards

The study was approved by the ethics review committee of the university. After evaluating the contents of the
survey instrument, the Committee assessed that the study would have no known risk to research participants. Verbal
consent was thus obtained; however, students were informed that they could decline participation and that they
could stop completing the questionnaire if they wished to. The benefits of the study (i.e., findings would be used to
draw attention towards mental health in Filipino students) were especially stressed in order to trigger a sense of
social responsibility and citizenship, and therefore, research participation among students. These instructions were
written on the cover page of the survey instrument that was administered. On the same cover page, we also included
our full names and contact numbers in which we enjoined students to ask us questions about the study and related
matters.

We did not seek the consent of the students’ parents anymore. The survey focused on real-life conditions (e.g.,
feeling bored and having low energy) which are normally shared between and among Filipino students. During our
pre-test of the questionnaire, student-respondents perceived the topic of the study as personally acceptable, one they
felt they would not be asking their parents for permission should they decide to discuss it. The foregoing ethical
standards, especially with respect to studies with no known harmful risks and the waiving of a signed certification of
consent, are in line with the practices of most Institutional Review Boards elsewhere.

Procedure

We conducted the survey in classrooms during the first quarter of the 90-minute classes. Each class was informed
about the importance and rationale, and the anonymity and confidentiality of the study. Afterwards, students were
invited to participate and were each given a questionnaire to accomplish. Students were reminded not to write any
mark in the instrument that would identify them. Whether completely accomplished or not, all questionnaires were
collected. Students were thanked for their participation. No incentive of any form was given.

Analysis

Using the Statistical Package for the Social Sciences Version 20, differences in the mean depressive symptoms
scores were examined based on social and demographic characteristics. The characteristics that were statistically
significantly related with higher levels of depressive symptoms were further examined at the sub-scale levels. The
analysis of variance was used.

The independent variables, except for sex (male, female), were recoded into variables with 2-3 categories each
(Table 2). The levels of closeness with parents and with peers were constructed by adding the scores corresponding
to responses given to the series of statements. For level of closeness with parents, the score range is 8 to 32 (low-
moderate, 8-23; high, 24-32); and for level of closeness with peers, the range is 9 to 36 (low-moderate, 9-26; high,
27-36). Our analyses revealed a high level of internal consistency for both series (parents: α=0.77; peers α=0.79).

Standard
Variables Categories N % Means
deviation
Sex Male 1063 43.6 71.39 19.21
Female 1373 56.4 71.47 18.18
Age category <17 1034 42.5 71.43 18.9
17 724 29.8 71.17 18.23
>17 674 27.7 71.75 18.71
Social sciences and
Course category 941 39.0 72.14 18.78
humanities
Business, economics and
714 29.6 70.02 18.15
management
Double major and
198 8.2 70.54 19.73
interdisciplinary
Engineering, natural
sciences and computer 561 23.2 72.47 18.57
science
Year level 1st 1731 71.1 71.16 18.69
2nd-4th 704 28.9 72.13 18.47
 Standard
Variables Categories N % Means
deviation
Religion Catholic 1968 80.9 71.55 18.38
Non-Catholic/others 466 19.1 71.04 19.69
Frequency of smoking (in
0 2108 86.5 70.84 18.50
days)**
≤10 182 7.5 76.82 18.64
>10 146 6.0 73.30 19.47
Frequency of drinking (in
≤10 885 36.5 73.29 19.03
days)**
>10 1541 63.5 70.33 18.28
Living with both
Yes 1895 77.9 70.99 18.51
biological parents*
No 539 22.1 72.99 19.03
Level of satisfaction with
one's financial Not satisfied 140 5.8 81.97 20.84
condition**
Somewhat satisfied 583 24.0 77.19 18.84
Satisfied 1252 51.6 69.19 17.43
Very satisfied 452 18.6 66.78 17.86
Level of closeness with
Low/moderate 427 17.5 81.65 19.77
parents**
High 2006 82.5 69.2 17.65
Level of closeness with
Low/moderate 289 11.9 84.58 20.69
peers**
High 2138 88.1 69.66 17.61
Table 2. Means and standard deviations for depressive symptoms scale scores by social and demographic
characteristics.

Academic
Variables Lethargy Cognition/emotion
motivation

p- p- p-
Means Means Mean
values values values
Frequency of
=0.001** =0.007** =0.000**
smoking (in days)
0 28.42 28.41 14.05
≤10 30.03 30.76 16.03
>10 29.51 27.62 16.24
F(2,2432)=6.56, SS=556.88, F(2,2432)=5.03, SS=1066.29, F(2,2432)=22.82, SS=1222.83,
MS=278.44 MS=533.14 MS=611.41
Frequency of
=0.001** =0.033* =0.000**
drinking (in days)
≤10 29.17 29.11 15.11
>10 28.29 28.18 13.87
F(1,2423)=10.28, SS=435.77 F(1,2423)=4.53, SS=479.96 F(1,2423)=32.03, SS=861.29
Living with both
=0.098 NS =0.042* =0.104 NS
biological parents
Yes 28.49 28.30 14.24
No 29.02 29.32 14.65
 Academic
Variables Lethargy Cognition/emotion
motivation

p- p- p-
Means Means Mean
values values values
F(1,2431)=2.65, SS=72.24,
F(1,2431)=2.74, SS=116.89 F(1,2431)=4.15, SS=441.32
MS=72.24
Level of satisfaction
with one’s financial =0.000** =0.000** =0.000**
condition
Not satisfied 31.37 33.69 16.91
Somewhat satisfied 29.91 31.83 15.46
Satisfied 28.09 27.40 13.76
Very satisfied 27.51 25.68 13.59
F(3,2422)=23.56, SS=2934, F(3,2422)=51.08, SS=15351.53, F(3,2422)=29.36, SS=2319.56,
MS=978.00 MS=5117.18 MS=773.18
Level of closeness
=0.000** =0.000** =0.000**
with parents
Low/moderate 30.74 34.35 16.56
High 28.16 27.29 13.86
F(1,2430)=56.15, SS=2342.5 F(1,2430)=176.73, SS=17563.84 F(1,2430)=98.06, SS=2571.45
Level of closeness
=0.000** =0.000** =0.000**
with peers
Low/moderate 30.86 37.10 16.91
High 28.30 27.37 13.98
F(1,2424)=39.59, SS=1658.98 F(1,2424)=248.31, SS=24038.13 F(1,2424)=82.43, SS=2178.29
Table 3. Means, F-values and p-values for depressive symptoms sub-scale scores by selected social and
demographic characteristics.

The dependent variable (levels of depressive symptoms) was constructed by adding the scores corresponding to the
responses given to the series of statements. The scale score ranges from 30 to 150 while the sub-scale scores range
from 9 to 45 for lethargy, 14 to 70 for cognition-emotion, and 7 to 35 for academic motivation; higher scores
suggest higher levels of depressive symptoms Our analyses revealed a high level of internal consistency for the
USDI (α=0.93).

Results
Profile of respondents

The majority were female while 43.6% were male. 42.5% were 16 years of age or younger, 29.8% were 17 years old
and a similar number were older. 39.0% were in social sciences/humanities; 29.6% were in
business/economics/management and 23.2% were in engineering/natural/computer sciences. Seven of every 10 were
first year students. Most were Catholic (80.9%) and reported not having smoked in the past 30 days prior to the
survey. In the past 30 days, about 6 of every 10 students had taken alcohol for more than 10 days, while 4 for ≤10
days. Most respondents (77.9%) currently lived with both biological parents. About 70% were satisfied and very
satisfied with their financial condition; the rest were not or were only somewhat satisfied. Most had high levels of
closeness with parents (82.5%) and peers (88.1%).

Differences in mean scale scores based on social and demographic

characteristics
The means and standard deviations for depressive symptoms scale scores are shown in Table 2. Higher means
suggest higher or more severe levels of depressive symptoms. Results indicate that male and female students did not
differ in their symptoms levels. No significant differences were observed across age groups. The level of depressive
symptoms statistically significantly varied according to course category but only marginally (F (3,2410)=2.54, p<.06).
Means were not significantly dissimilar across year level and religion.

Means comparison related to frequency of smoking suggests significant differences among the categories
(F(2,2411)=9.65, p<.01). Results of post-hoc Tukey test indicate that those who smoked for ≤10 days had a higher level
of depressive symptoms than those who did not smoke in the past 30 days (p<.01). Significant means differences
were observed based on frequency of drinking (F(1,2424)=14.31, p<.01). Students not living with both parents had a
significantly higher level of symptoms compared to those living with parents (F (1,2432)=4.87, p<.05). Moreover,
depressive symptoms level significantly varied according to satisfaction with one’s financial condition
(F(3,2423)=52.03, p<.01). Based on post-hoc Tukey test findings, students who were not satisfied with their financial
status had a more elevated level of depressive symptoms than those who were somewhat satisfied (p<.05), satisfied
(p<.01) and very satisfied (p<.01).

Students with a low to a moderate level of closeness with parents had a significantly higher level of depressive
symptoms than students with a high level of closeness with parents (F (1,2431)=165.76, p<.01). Students with a low-
moderate level of closeness with peers had a significantly higher level of symptoms than those with a high level of
closeness with peers (F(1,2425)=176.91, p<.01).

The 6 independent variables with statistically significant relationships with higher levels of depressive symptoms
were further examined for their interactions. The two-way analysis of variance results indicate an absence of any
interaction.

Differences in mean sub-scale scores based on statistically significant

social and demographic factors

Additional analyses using the one-way analysis of variance were performed to determine if the statistically
significant associations of the 6 independent variables (i.e., frequency of smoking, frequency of drinking, living/not
living with both biological parents, level of satisfaction with financial condition, level of closeness with parents, and
level of closeness with peers) would hold at the sub-scale level. The means, F-values and p-values are given in Table
3.

Results indicate that the associations of the 5 variables (i.e., frequency of drinking, level of satisfaction with
financial condition, and levels of closeness with parents and with peers) persisted at all sub-scales of depressive
symptoms (p-values at <0.01 or <0.05). The significant sub-scale association of the remaining variable (i.e.,
living/not living with both biological parents) was confined only to the cognitive-emotional sub-scale.

Discussion
This survey identified a set of social and demographic factors that are statistically significantly associated with
higher levels of depressive symptoms among Filipino university students. The aim is to help prevent depression
among the domestic university student population. If students with elevated risks are known and assisted early, their
depression would be promptly averted. Data suggest that the factors with significant associations with depressive
symptoms, mostly at both the scale and sub-scale levels, were frequency of smoking, frequency of drinking,
living/not living with both biological parents, level of satisfaction with one’s financial condition, and levels of
closeness with parents and with peers.

The significant associations of frequencies of smoking and of drinking with depressive symptoms are aligned with
extant empirical findings [20,21]. The present study revealed that Filipino students who smoked for some days
(against those who did not smoke) and who took alcohol for some days (against those who consumed alcohol for
longer durations) had higher depressive symptoms levels. In explaining the associations of smoking and drinking,
some studies tend to highlight the psychopharmacological [20] and symbiotic [22] dimensions of these bivariate
relationships. This implies that students could have smoked or taken alcohol as an escape route from the burdens of
psychosocial difficulties. In the case of drinking, in particular, the use of alcohol usually precedes the symptoms of
lethargy and social difficulties associated with depression [23,24]. Caution should be taken in appreciating these
interpretations, however. The variables were measured in this study based on the number of days of smoking and
drinking rather than the quantities of cigarettes and alcohol consumed (these two are not necessarily equivalent
indicators). Considering that the rates of smoking and drinking among the Filipino youth are relatively high (21.0%
and 41.4%, respectively) [25], these twin behaviors, specifically their frequencies, need closer examination vis-à-vis
depressive symptoms.

The association between not living in the household with both biological parents and having more serious levels of
depressive symptoms has ample empirical support [14,26]. Across the country, many Filipino students do not reside
with both parents while pursuing their university education, because they live away from home in dormitories and/or
their biological parents are single, separated, or are working abroad. Either as a permanent or a temporary condition,
not living with both biological parents may induce depressive symptoms, primarily in cognitive-emotive terms as
this study revealed, probably as a result of having restricted access to parental presence and support.

Satisfaction or dissatisfaction with one’s financial condition is well-confirmed in several other investigations for its
significant role in mental health [27]. It is usually expensive to study in a private Philippine university compared to
studying in the country’s state colleges and universities. Students in private universities would generally belong to
higher levels of socioeconomic status and may influence a peer culture that promotes greater awareness of a
person’s socioeconomic standing in society. Such an educational environment is, in turn, likely to enhance
sensitivities about one’s own social status in comparison to one’s peers. Those who perceive themselves as higher in
status also have higher levels of optimism and perceived control, and therefore, are also likely to exhibit lower levels
of depressive symptoms [28,29].

The current study findings on the significant associations between the levels of closeness with parents and peers and
depressive symptoms are to be expected; these are within the realm of the evidence widely reported in other
investigations [7,30]. That most of the Filipino university students who participated in this study had high closeness
levels with their parents and peers is hardly unexpected. Parents and friends are basic yet very significant primary
groups for Filipino adolescents. Their provisions, including the immediate care, security and support that they
bestow and the secure attachments that they consequently foster, are effective protectors and buffers of university
students against depressive symptoms [31,32].

In the absence of high level of closeness of Filipino students with parents, in which the parent-child relationship
would be characterized by communication problems, excessive parental control, low levels of cohesion, and high
levels of conflict in the families, adolescents are bound to experience depressive symptoms [33,34]. Without high
level of closeness with peers, local students are also predisposed to be at risk. Students are in a stage when they
mostly need their peers for emotional support. Peer acceptance is important to the growing individual and is
therefore associated with depressive symptoms [35]. Compared to the association of the lack of parental warmth and
acceptance with adolescents’ depressive symptoms, which is largely unidirectional, the association between
depressive symptoms and peer-relational problems tends to be bidirectional [36]. Filipino students exhibiting
depressive symptoms are likely to be spending less time interacting with their peers and are prone to relate with
them aggressively. This interaction pattern, in turn, is likely to cultivate further peer rejection and neglect.

Sex, age category, course category, year level and religion were not statistically significant factors as our analyses
revealed. As a general rule, females show higher rates of depression than males [37,38] due to their tendency to be
more expressive and more sensitive to the support provided by their social networks [39]. However, this normative
rule on gender differences does not seem to hold true for university students [37]. The exception may be accounted
for by the homogeneous university life experiences, similarities in parental education, or common socio-
demographic conditions among the youth in general [37,39]. The lack of significant associations of age category,
course category and year level among Filipino students could be due to this homogeneity factor as well, particularly
that most of them were young, freshmen and completing general education rather than major subjects at the time of
their interview. Religion was not significantly associated with depressive symptoms and this is to be expected: the
Filipino youth, including university students, are largely nominal Catholics who seldom practice their faith [40].
Elsewhere, one’s religiousness rather than religious affiliation per se has been observed to be significantly related
with lower levels of depressive symptoms in students [41].

The survey has some limitations. Since the study’s respondents were from general education classes with mostly
first year students from middle- and high-income backgrounds, the findings cannot be generalized to the entire
student population of the university surveyed or student populations from other universities in the Philippines.
Another limitation of the survey is that it did not include other factors that may have potential relationships with
higher levels of depressive symptoms. For instance, since completing a university degree is culturally valued among
Filipinos, the academic performance of students could be a critical factor for assessing depressive symptoms. Also,
the study is cross-sectional, and as such, its conclusions only refer to associations rather than causal relationships
between the independent and dependent variables. Moreover, the level of depressive symptoms measured through
the USDI pertains not to the sequence of the occurrence of high levels of depressive symptoms, but to the amount of
depressive symptoms weighted by frequency of occurrence students experienced in the past fortnight.

More surveys using the USDI are needed in the Philippines. Future studies have to involve representative samples of
Filipino university students from other socio-economic backgrounds. If feasible, longitudinal studies, which will
provide repeated observations of the levels and associated factors of depressive symptoms, are a better alternative.
Variables related to students’ academic performance should be included as well. Some variable measures (e.g.,
frequency of smoking) need to capture more nuanced dimensions of the social and demographic conditions of
students at greater risk, For example, variables related to smoking and drinking should ask follow-up questions
regarding the specific quantities of cigarettes and alcohol consumed by students in a given period. In addition, the
association of religion with depressive symptoms will be better understood by a follow-up question on religiousness.

Conclusion
The present survey is a pioneering large-scale research on the social and demographic factors of higher levels of
depressive symptoms among Filipino university students. These initial findings can help guide the development of a
campus-based prevention program at the university surveyed. Towards addressing depressive symptoms and
depression in students, lifestyle and factors related to financial condition and parental and peer relationships are
important considerations for identifying those at greater risk. More research is needed towards building additional
local knowledge on the topic.
Author Contributions
Conceived and designed the experiments: RBL MS SE CR. Analyzed the data: RBL MS SE CR. Wrote the
manuscript: RBL MS SE CR.

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https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0079825#s1
The Development of a Community-
Based Drug Intervention for Filipino
Drug Users

Abstract
This article documents the development of a community-based drug intervention for
low- to mild-risk drug users who surrendered as part of the Philippine government's anti-
drug campaign. It highlights the importance of developing evidence-informed drug
recovery interventions that are appropriate to the Asian culture and to developing
economies. Interviews and consultations with users and community stakeholders reveal
the need for an intervention that would improve the drug recovery skills and life skills of
users. Evidence-based interventions were adapted using McKleroy and colleagues’
(2006) Map of Adaptation Process (MAP) framework. The resulting intervention
reflected the country's collectivist culture, relational values, propensity for indirect and
non-verbal communication, and interdependent self-construal. The use of small groups,
interactive and creative methodologies, and the incorporation of music and prayer also
recognised the importance of these in the Philippine culture.
The past decades have seen increasing concern for substance use, and the United
Nations Office of Drugs and Crime (UNODC) reports that 2.3% of the world's population
abuses illicit substances (UNODC, 2014). The Philippine Drug Enforcement Agency
(PDEA) also reported that 92% of barangays 1 in the National Capital Region are
affected by illicit drug use (PDEA, 2015). In July 2016, newly elected President of the
Philippines Rodrigo Duterte declared a ‘war’ against illicit drugs. Dubbed ‘Operation
Double Barrel’ or Oplan Tokhang, 2 the campaign involved efforts at demand reduction
and supply reduction. Supply reduction involved shutting down drug laboratories and
arresting drug suppliers. Demand reduction activities involved community officials
and/or local police going to the homes of known users and asking them to voluntarily
surrender and receive treatment. As of March 2017, 1.18 million illicit drug users have
surrendered (Raymundo, 2017) with an additional 44,070 arrests and 2,206 fatalities
(Palatino, 2017). However, beyond these legal measures, the Human Rights Watch
(2017) reports that the Philippine National Police and unidentified vigilantes have killed
about 7,000 suspected drug users and pushers in what are now termed extra-judicial
killings.
The staggering numbers highlight the urgent need to develop and implement drug
treatment programs. However, because drug treatments are costly and generally
inaccessible to the poor, the UNODC (2014) suggested the necessary provision of
community-based drug recovery support. This involves providing holistic care in the
form of preventive education, health promotion, screening, treatment and rehabilitation
services, primary health services, basic support, education, skills training, and livelihood
opportunities in communities (UNODC, 2014). Beyond being cost-effective, there is
evidence that community-based drug interventions have significantly decreased hospital
stay, emergency room visits, and criminality (UNODC, 2014).
The Dangerous Drugs Board (2016) of the Philippines reported that 90% of those
who have voluntarily surrendered could be treated in the community (Cepeda, 2016).
However, like most countries in Asia, the Philippines has primarily employed
compulsory residential treatment in resolving illicit drug use problems (Vuong et
al., 2017). Given the overwhelming number of clients, communities have created their
own programs consisting of community service (e.g., cleaning, beautification, tree
planting, gardening), recreational activities (e.g., sports activities, Zumba, yoga),
counselling, and spiritual formation (e.g., bible study, prayer groups).
International guidelines advocate the use of evidence-informed and culturally
nuanced drug treatments (UNODC, 2014). Although there is literature on evidence-
based community interventions, they have emanated from developed and Western
countries, and there is a dearth of literature from low- to middle-income countries
(LMIC) in Asia. This study sought to fill the gap by describing the adaptation and design
of a community-based drug recovery program for low- to mild-risk Filipino users. It
further adds to the literature by highlighting the psychosocial needs of Filipino users and
cultural and contextual considerations, thus supporting models of program adaptation
that incorporate stakeholder and cultural factors.

Community-Based Programs
The UNODC (2014) describes illicit drug use as a complex health condition that has
social, psychological, and biological dimensions. Rather than addresssing illicit drug use
from a criminal justice perspective, UNODC advocates that it should be treated as a
health condition with community-based treatment offered as an alternative to
incarceration when possible. In contrast to centre-based residential rehabilitation,
community-based treatment is primarily outpatient rehabilitation. Community-based
treatment programs ascribe to the following key principles: minimal disruption to
stakeholder support systems, comprehensive continuum of care, evidence-based
practices, acceptance of program implementers, and culturally appropriate
(UNODC, 2014). This approach acknowledges the complexity of drug use and involves
the client's family and the community to ensure efficient and long-term results. The
UNODC advocates a holistic approach that includes needs assessment, treatment
planning, program implementation, and case management. Another key principle in
community-based treatment is the provision of a continuum of care that takes a
comprehensive approach in addressing the stakeholders’ general health, family,
education, and employment needs. It also highlights the active role of people affected
by drug use and their families and community members in the service planning and
delivery (UNODC, 2014).
UNODC also recommends the use of evidence-based treatments, and there is
growing literature on outpatient treatments for illicit drug use and misuse (McCarty et
al., 2014). The most robust evidence has been reported on cognitive behaviour therapy
(CBT; Windsor, Jemal, & Alessi, 2015). CBT assumes that drug use is a learned
behaviour and thus can be unlearned through therapeutic strategies (Magill &
Ray, 2009). It focuses on changing behaviours by addressing maladaptive cognitions
and emotions that shape behaviour (Beck, 1970). Another popular approach that has
been shown to produce small but sustained reduction in substance use is motivational
interviewing (MI; Sayegh, Huey, Zara, & Jhaveri, 2017). MI assumes that people will not
change simply because they are told to do so and that real change needs to come from
within. It is a client-focused approach that aims to elicit internal motivation to change
through the experience of empathy, increasing an internal sense of discrepancy
between ones's goals and values and one's current situation, and fostering a sense of
self-efficacy and optimism (Miller & Rollnick, 2012). The community reinforcement
approach (CRA) involves the use of rewards to spur positive behavioural changes
(Roozen et al., 2004). Founded on operant conditioning and behavioural modification
principles, clients are encouraged to set goals and are given rewards for achieving
sobreity-related behaviours and goals. It has been found effective for people with
alcohol use problems and has been adapted for illict drug use (Meyers, Roozen, &
Smith, 2011). Finally, another program that has evidence of effectiveness is the 12-Step
Program (Ouimette, Finney, & Moos, 1997). The 12-Step Program is founded on a
belief of a ‘power greater than oneself’ among recovering users. Its principles include
accepting addiction as a disease, embracing sobriety, surrendering to a higher power,
self-reflection and assessment, seeking reparation, and deepening one's faith. It
highlights the importance of mutual support though sponsors and participation in 12-
Step community sessions (Baker, Daley, Donovan, & Floyd, 2009).
Given the many alternatives, a critical factor in selecting community-based
strategies is the acceptance of those who will implement them. A study among
community mental health staff reports that they are more inclined to use interventions
that are flexible and easy to implement (Nelson, Steele, & Mize, 2006). Resistance to MI
was mostly due to perceived difficulty and the lack of training. Challenges in the use of
CBT include perceived low motivation and cognitive ability of patients, and psychiatric
instability of some clients. Barriers to using CRA include difficulty in certification
requirements, resistance from clients, and the lack of resources to implement (Amodeo,
Cohen, Chassler, & D'ippolito, 2011). The challenges cited for the12-Step Program
were resistance from clients, non-participation and attendance, possibility of one client
dominating the discussion, and the need of clients for answers or solutions to their
problems (Baker et al., 2009).

Considerations in Implementing Community-Based

Interventions in the Philippines
Beyond utilising evidence-based interventions, international guidelines advocate the
adaptation of evidence-based treatment methodologies to local context and culture
(UNODC, 2014). Cultural adaptation requires understanding local culture and context. A
major challenge in implementing community-based drug treatment in the Philippines is
the lack of resources allocated for mental health services. The country's budget for
health is only 2–3% of the national budget, and mental health is a low priority. There is
also a dearth of mental health professionals, as well as a disparity in their distribution.
For example, there is only one licensed psychologist for every 100,000 Filipinos, and
most psychiatrists and psychologists are located in urban areas (Hechanova et
al., 2015).
 Another possible barrier to community-based interventions is the prevailing stigma
on drug users and a reluctance to seek treatment (Hechanova, Tuliao, Teh, Alianan, &
Acosta, 2013; Tuliao, Velasquez, Bello, & Pinson, 2016). Studies report that Filipinos
are generally reluctant to open up to strangers because they believe that seeing a
professional means they are crazy, and this will tarnish the reputation of their family
(Hechanova et al., 2013). Rather than professionals, Filipinos prefer to seek help from
family, friends, religious leaders, and folk healers (e.g., Abe-Kim, Gong, &
Takeuchi, 2004; Tuliao, 2014).
The Philippines has also been described as a collectivist and interdependent
culture. Filipinos have a difficult time saying ‘no’ to friends and family (Hechanova &
Waelde, 2017; Tuliao, 2014). On the one hand, the tendency to conform can be a
challenge for drug users who want to quit. On the other hand, this can be harnessed by
incorporating reference groups into the intervention strategy (Dueck & Byron, 2012).
This is supported by evidence that group-based interventions are a good venue for
healing among Filipino survivors (Hechanova et al., 2015; Hechanova, Waelde, &
Ramos, 2016).
The Philippine culture is strongly rooted in spiritual and religious traditions. Filipinos
draw inner strength and support from their faith, and this functions as a protective factor,
especially among survivors of natural disasters (Hechanova et al., 2015; Hechanova &
Waelde, 2017). Participation in church rituals and prayer groups is a means to cope,
and religious communities are important social capital (Nakonz & Shik, 2009). As such,
community-based interventions may harness psycho-spiritual resources to enable
healing.
Finally, another consideration in designing psychological interventions in the
Philippines is emotional expression. The Philippine culture has roots in Chinese culture,
and a common belief among Chinese is that talking about painful issues and
experiences causes excessive and unbalanced emotions that lead to illness
(Haque, 2010). Dueck and Byron (2012) suggest that in such cultures, projective
approaches, such as using art and theatre, can facilitate emotional expression. Studies
show that disaster interventions in the Philippines incorporate music (e.g., Hechanova
et al., 2015) and other art forms (e.g., Parr, 2015).

Research Problem
Given that cultural nuances are important in the cultural adaptation and design of
community-based interventions, this article documents the development of a
community-based drug recovery intervention for low- to mild-risk illicit drug users in the
Philippines. This study used McKleroy and colleagues’ (2006) Map of Adaptation
Process (MAP) framework, which prescribes five phases: (1) assessment of the needs,
risk factors, and implementation considerations; (2) developing the intervention model
and determining adaptations; (3) training facilitators and pretesting the materials; (4)
pilot-testing; and (5) implementation of the adapted intervention. This article describes
the first three phases of the aforementioned process and sought to answer the following
research questions:
1. 1. What are the psychosocial needs and risk factors of Filipino drug users?
 2. 2. What cultural factors need to be considered in the design and adaptation of
the modules?
3. 3. What are the factors that need to be considered in the delivery of the
modules?

Methods
The study utilised a mixed-method design using multiple data sources such as
interviews with drug users and focused group discussions with community stakeholders.

Needs Analysis Interviews

In-depth interviews were conducted in Metro Manila among 48 illicit drug users who had
voluntarily surrendered and consented to participate in the interviews. The majority of
participants were male (n = 35, 72%), married or co-habiting (n = 30, 64%), with an
average age of 36 years (range 18–50 years). About half (n = 25, 52%) were employed
in manual and contractual work (e.g., construction work, electrician, street sweeper).
The majority reported they had used methamphetamine (n = 34, 70%), followed by
marijuana (n = 10, 20%) and inhalants (n = 5, 10%).
The interview questions included the following: (1) How did you start taking illicit
drugs? (2) Have you tried to stop using illicit drugs? What happened? (3) What were
you feeling, thinking, or doing the last time you used illicit drugs? (4) What are the
benefits you get from using illicit drugs? (5) What are the negative effects of illicit drugs
on you? (6) What do you do when you feel the craving to use? (7) What or who made
you want to stop using illicit drugs? (8)What are your dreams in life? What are your
plans to achieve these dreams? (9) Have you tried asking for help to stop using illicit
drugs? Why or why not? (10) What help would you need to stop using illicit drugs?

Drug dependence
The World Health Organization (WHO) ICD-10 Symptom Checklist was verbally
administered to measure drug dependence symptoms (WHO, 2004). The items include
cravings, control of use, withdrawal symptoms, pattern of use, neglect of other interests
in favour of drug use, experience of physical or psychological harm, and persistence of
use despite consequences. Drug dependence is indicated if three or more symptoms
are present.

Consultations With Community Stakeholders

Two consultation discussions were conducted with community stakeholders. The first
consultation aimed to obtain contextual and cultural considerations to aid in the design
adaptation of the drug-recovery intervention. The second consultation aimed to validate
the design of the intervention and elicit considerations in the delivery of the intervention.
The first consultation was conducted with 15 mental health professionals (39%),
three addiction counsellors (8%), and 20 community stakeholders, including recovering
users (52%). Individuals were invited based on their exposure to drug use and
involvement in existing community-based drug rehabilitation. Stakeholders were divided
into smaller groups, assigned a component of the model, and tasked to examine the
Matrix Intensive Outpatient Program (MIOP) of the Substance Abuse Mental Health
Services Administration (SAMHSA, 2006) and the UNODC (2015) Trainer's Manual:
Community-Based Services for People Who Use Illicit Drugs in Southeast Asia. Groups were
asked to examine the draft modules based on three facets: (1) deep structure, (2)
surface structure, and (3) delivery. Participants were asked the following questions: (1)
To what extent is the core theory of change consistent with the characteristics, beliefs
and norms of the target population? (deep structure); (2) To what extent does the
methodology, message and materials match the target population? (3) What other
factors should be considered in the design of the intervention? (surface structure).
The second consultation aimed to validate the design and obtain inputs from
stakeholders on program implementation and delivery. Participants from the previous
design meeting were invited, but only 29 were able to attend. The group was composed
of 59% community stakeholders (n = 17), 32% mental health professionals (n = 9), and
10% addiction professionals (n = 3). The draft modules were presented and community
stakeholders were asked the following questions: (1) To what extent does the
methodology, message and materials match the target population? (2)What factors
need to be considered in the delivery of the intervention?

Procedure
Ethics approval was obtained from the Ateneo de Manila University Institutional Review
Board. Informed consent was obtained from all participants in this study. Participants
were assured that all information would only be for research purposes and would not be
revealed to community officials. To protect the privacy and confidentiality of
interviewees, interviewers asked them not to use their real names or cite real names of
other people. The data were accessible only to researchers who were not members of
the community. The data from interviews and consultations were thematically analysed.
After an initial read through of the data, themes were identified, and another researcher
was assigned to perform a frequency analysis of these themes.

Results
Profile of Illicit Drug Users
Severity of drug dependence
Based on the prescribed cut-off scores on the ICD-10 scale of psychoactive substance
use (WHO, 2004), results showed only 14% of participants had scores indicative of full
dependency, 39% had some symptoms, and 47% had no symptoms of drug
dependence. The most frequently identified dependence symptoms were compulsions
or cravings, neglecting responsibilities and interests, and continued use despite harmful
consequences.
Chronic nature of drug use
The results of the interviews confirmed the chronic nature of drug use. Half of
participants (50%) had attempted to quit. Of these, 18% had lapsed once, 41% had
lapsed twice, 12% had lapsed thrice, 12% had lapsed 4–6 times, and 17% lapsed more
than this.

Reasons for drug use

The interviews indicated four factors influencing use: peers, family, work, and personal.
The most common reason given for use and lapse was peer influence (‘My friends
invited me’), family problems (‘My father beats me’, ‘My wife and I separated’, ‘Fights at
home’) and family influence (‘My uncle was using’). Others cited work reasons (‘Gives
me more energy’, ‘I can work better’). Individual factors included the desire to
experiment (‘I just wanted to taste’), mood (‘Wanted to feel good’), and boredom (‘Didn't
have work, nothing to do’).

Benefits of drug use

The most commonly cited benefit (45%) of drug use was increased energy and
productivity (e.g., ‘Lets me stay awake’, ‘Feel less tired, more energised’). Participants
described a tamang sipag (energy trip) that allows them to work longer and harder. The
second most common benefit mentioned (23%) was positive mood (‘I felt happier’).

Negative effects of drug use

A number (43%) of participants did not report any negative effects from using illicit
drugs. However, those with dependence symptoms reported negative effects on their
health (e.g., stroke, stomach aches, dry skin), relationships (e.g., separation of family,
marital conflicts), and mood (e.g., bad temper, irritability). Other negative impacts
included illegal activities (theft), financial losses (‘Money for family went to illicit
drugs’), tamang hinala (paranoia) and mental health issues (hallucinations).

Help-seeking
The majority of participants (55%) said they had never sought help for their drug use
because they felt they did not need help (‘I thought I could stop on my own’) or felt that
drug use was not a problem (‘I can stop any time’). Those who had sought help had
approached their family (76%), a church (14%), or community member (14%). However,
there were also those who did not know who to approach (‘I didn't know who to ask’) or
were ashamed to seek help (‘I was ashamed’).

Coping strategies
Non-dependent users reported adaptive coping strategies such as avoidance (‘I stay at
home’), looking for distraction, keeping busy, exercise, thinking about impact on family,
praying, sleeping, and eating. However, those with dependence symptoms reported
non-adaptive behaviours such as resorting to drug use (‘I take again’), coercing family
members for money to buy illicit drugs (‘I make my wife give me money to buy illicit
drugs’), and even stealing or pushing to obtain the funds to buy illicit drugs.

Motivation to change
The majority (60%) of participants stated their motivation to stop was their family. They
reported pressure from their families to stop, as well as a desire to provide a better life
for their families. Sixteen percent cited community officials and the fact that they were
personally approached. Fourteen percent said they wanted to quit for themselves and
cited personal goals (i.e., desire to have steady work, to continue studies, achieve
career goals and improve their health). However, they also were not clear on how to go
about achieving these. About 9% cited the government's drug war and the fear of being
incarcerated or killed as the reason they surrendered.

Support needed
When asked what support they needed, 57% of the participants cited job opportunities
and 56% cited emotional support from family. About a third (36%) cited community
programs for recovering users and 15% verbalised their hope that their communities
could keep them safe and protect them from pushers and vigilantes.

Considerations in the Design of the Intervention

Consistency of core theory of change with the target population
Stakeholders affirmed the importance of the interventions. As one participant said:
‘People say “Just say no”. If it is that easy, there would be no drug addicts. The question
is, how do you say “no”?’ They observed that current initiatives such as community
service, prayer sessions, and exercise programs were helpful diversions but not
adequate (‘Zumba and prayer can only do so much’). Stakeholders reported attrition
and a return to illicit drug use among those in community diversion programs. As
explained by one community member: ‘The motivation to quit is there, but that's not
enough if they don't know how.’ This validated the importance of focusing on changing
motivations, behaviours, cognitions, and emotions to help drug users stay sober.

Literacy and learning style

Stakeholders affirmed the relevance of the MIOP and UNODC modules but raised
concerns about their suitability given participants’ low literacy levels. Stakeholders
suggested the need to simplify the modules and use fewer cognitive approaches: ‘Our
participants can't read or write, so worksheets and reading materials won't work.’ This
validated the data obtained that clients were predominantly under-educated. Community
stakeholders also suggested using videos, visuals, physical activities, and creative
methodologies such as storytelling, music, and art to engage participants.

Resources for implementation

The stakeholder consultation also highlighted the lack of preparedness and resources of
local government units to implement community-based drug recovery support.
Participants reported the lack of budget, facilities, manpower, and resources to
implement these programs and, given this, suggested the need to minimise required
materials and equipment.

Religious beliefs
Finally, stakeholders suggested the importance of acknowledging participants’ religious
beliefs in the design of modules. Although some suggested the inclusion of Bible
verses, others felt that this would exclude Muslim and non-Christian participants.
Addiction professionals suggested the use of ecumenical prayers such as the Serenity
prayer (popularised by the 12-Step Program), given the possible diversity of
participants.

Design and Adaptation of the Intervention

Based on the needs analysis and stakeholders’ inputs, 12 modules were designed for
low- to mild-risk users. The first six modules focused on drug recovery skills and were
based on the Brief Assist Intervention by the WHO (2010), the MIOP (SAMHSA, 2006),
and the UNODC's (2015) Manual on Community-Based Services. The next six modules,
which were focused on developing life skills, were adapted from SAMHSA's (2006)
MIOP and Katatagan, a resilience program developed for Filipino disaster survivors
(Hechanova et al., 2015).
The modules were founded on principles of MI that focus on eliciting internal
motivation and enhancing self-efficacy. CBT principles were used to shape ineffective
thoughts, emotions, and behaviours. Mindfulness was also incorporated in each module
to centre participants and build their capacity for self-awareness and self-regulation.
Given the collectivist culture, the intervention was designed to be delivered in the form
of structured group sessions. Each module consisted of specific parts: welcome,
mindfulness-centring exercise, review of previous session and homework, module
proper, reflection on insights, homework, and closing. Modules were designed using
principles of adult learning; namely, salience (based on needs), practice, application
and reinforcement (exercises, role-playing, application, and homework). Recognising
the value of the arts in Philippine culture, drawing activities are used when appropriate,
and sessions end with a prayer or a song. Even though the Serenity prayer was
suggested, the manual emphasised the flexibility of facilitators in choosing appropriate
prayers or songs depending on the religious beliefs of their participants.
 The introductory module (Understanding Drug Addiction), aims to educate the
participants about the effects of illicit drugs and the nature of addiction. The session
begins with a local video on the experiences of Filipino drug users that serves as a
springboard to elicit participants’ own experiences. This is followed by a discussion on
stages of drug use, the impact of illicit drugs, and the myths about drug use. An
overview of the entire program is presented and participants are invited to attend the
program. Because studies show that groups enable healing in interdependent and
collectivist cultures (Hechanova et al., 2015; Hechanova et al., 2016), participants are
asked to come up with a group name in order to build social support and a sense of
group identity. Recognising the interdependent nature of Filipinos, the homework for this
session is to ask family and friends how the participants’ drug use had affected them.
Module 2 (Importance of Change) is based on MI theory that proposes that real
change happens when it comes from within (Miller & Rollnick, 2012). The highlight of
the module is the processing of the discrepancy between participants’ actual and ideal
life and identifying their motivations for changing. Participants are also asked to reflect
on the importance and their readiness and self-confidence in remaining sober.
Recognising the interdependence on and central role of family and friends for Filipinos
(Enriquez, 1978), the homework for this module is for participants to ask their family
and/or friends how important is it for them to change.
Module 3 (Coping with Cravings) was designed to respond to the finding that users
lacked adaptive coping skills to remain sober. The module recognises that cravings are
an inherent part of recovery and focuses on strategies to manage cravings (e.g., delay,
distract, decide; thought stopping and thought substitution). Given the low literacy level
of participants, these concepts are taught using interactive methodologies such as
structured learning experience, drawing of symbols, and the creation of a slogan.
Most interviewees cited external triggers as reasons for use. Given this, Module 4
(Managing External Triggers) begins with a structured learning experience where
participants are asked to go through an obstacle course while blindfolded. They are
then asked to reflect on the role of one's environment and the importance of being
aware of the external factors — people, places, things or events that trigger their use.
Cognisant of Filipinos’ concern to protect family members and friends from shame
(Hennig, 1983; Lynch, 1962), participants are asked to use pseudonyms.
The interviews highlighted the influence of peers on drug use. Module 5, entitled
‘Saying No’, aims to develop drug refusal skills. These skills are particularly important
given the country's interdependent culture and the fact that Filipinos have a difficult time
saying ‘no’ to friends and family (Hechanova & Waelde, 2017; Tuliao, 2014). In the first
part of the module, participants are asked to rate friends and relatives on the extent of
their influence on their drug use. This is followed by a discussion on ways they can
avoid interactions with these people. The second part is spent role-playing different
ways of refusing offers of illicit drug use
The goal of drug recovery does not only include abstinence but also the
achievement of improved health and quality of life. Module 6 (Adopting a Healthy
Lifestyle) seeks to address the negative effects of drug use by equipping participants
with various self-care strategies. It uses the Eight Dimensions of Wellness (i.e., social,
environmental, occupational, spiritual, material, emotional, intellectual, and physical),
which was chosen because of its inclusion of spirituality (SAMHSA, 2016). Faith is often
cited in local literature as an important means of support for Filipinos (Hechanova &
Waelde, 2017; Ladrido-Ignacio, 2011). They see hardships as spiritual opportunities,
prayer as a means of coping, and religious communities as an important social resource
(Nakonz & Shih, 2009).
The needs analysis revealed that negative emotional states are triggers for use.
Module 7 (Managing Thoughts and Emotions) aims to help participants manage
negative emotions through the use of CBT principles, specifically Ellis's ( 2001) ABC-
DEF Model of Emotional Disturbance. However, a study among Filipino disaster
survivors revealed that participants have difficulty parsing thoughts from feelings
(Hechanova et al., 2015). To aid participants, the module begins with a vignette to
highlight the relationship between emotions, thoughts, and behaviours. Participants are
then shown ambiguous pictures, leading to a discussion on interpreting the same
precept in different ways. This is followed discussion and exercises on disputing
irrational beliefs and developing alternative thoughts that can lead to new emotions and
behaviours. An acronym was created using Filipino terms to enable better recall of this
reframing process.
The interviews revealed that drug use led to aggressive behaviour, relationship
problems, and isolation. The literature highlights the Filipino value of kapwa (‘unity of the
self with others’; Enriquez, 1992) and the importance of maintaining good relations
(Lynch, 1962). Module 8 (Relating to Others) aims to improve participants’ relationships
with families and friends by developing interpersonal skills. Because communication is a
key ingredient in successful relationships (e.g., Nicotera, 1993), this module focuses on
communication styles and the importance of active listening. Because of Filipinos’
tendency to rely on non-verbal behaviour and pakikiramdam, or relational sensitivity to
others (Reyes, 2015), the module includes an exercise on sensitivity to non-verbal
behaviours.
The interviews revealed the existence of broken relationships because of drug use.
Recognising the central role of family and friends in a collectivist culture
(Enriquez, 1978), Module 9 (Rebuilding Relationships) aims to begin the process of
rebuilding connections by enabling participants to reflect on how they may have been
hurt as well as hurt others. Participants are invited to contemplate on their readiness to
forgive others as well as ask for forgiveness from others. The module ends with a self-
compassion exercise encouraging participants to move towards forgiving the self, a
major component of compassion-focused therapy (Gilbert, 2014). As part of their
homework, participants are asked to make amends with someone they may have hurt in
the past.
Recovering users shared multiple problems such as poverty, lack of stable work,
conflicts with family, separations, lack of education, and so on. Given these concerns,
Module 10 (Problem Solving) focuses on problem-solving skills. It begins with a
vignette, and participants reflect on a chain diagram of interrelated problems and
identify what might be the root problem. Participants are asked to identify a current
problem, brainstorm possible solutions, identify barriers to solving the problem, decide
on the most appropriate solution, and plan how to implement it. A cultural nuance in this
module involves asking participants whether the problem they cited is within their
control. This is because a study reveals that Filipinos tend to take on other people's
problems as their own (Hechanova et al., 2015). Based on evidence that for Filipinos,
extended family and community members are a critical source of support (Hechanova et
al., 2015), participants are also asked to identify possible sources of support.
Interviewees cited experiencing hiya (shame) and loss of face because of the
stigma of illicit drug use. Given this, Module 11 (Recognising My Strengths) focuses on
building participants’ self-esteem and self-efficacy. The module asks participants to
identify their strengths as well as their areas of improvement. Given the aforementioned
interdependent culture, participants are invited to affirm each other to strengthen
participants’ self-efficacy and self-esteem. As part of their homework, participants are
asked to also obtain feedback from family and friends.
In the final module (Meaning Making and Looking to the Future), participants are
invited to reflect on the meaning of their experiences of illicit drug use and what they
have learned from it. Given the results of the needs analysis that most recovering users
had aspirations but no concrete plans on how to achieve their goals, participants are led
through a visioning and planning exercise. The interviews also revealed that
participants’ motivations mostly revolve around their family. This is consistent with
findings that, rather than self-actualisation, what is important for Filipinos is the
actualisation of their family members (Ilagan, Hechanova, Co, & Pleyto, 2014). Thus,
the process of planning for one's future recognises that participants’ dreams are not just
for themselves but may also revolve around their families.

Implementation Considerations
The second consultation with community stakeholders and addiction professionals
sought to validate the design of the interventions and identify considerations for
implementation. Participants affirmed the overall design, objectives, and content of the
modules. However, they raised a number of factors relevant to the design.

Language and content

Although community stakeholders appreciated that the modules were written in the
national language, they commented that some Filipino terms used were unfamiliar.
Some stakeholders were concerned that Filipino is not the native language in Central
and Southern Philippines, and some key words mean different things
(e.g., libang means ‘to distract’ in Tagalog-based Filipino but means ‘to defecate’ in
Cebuano). A suggestion was to translate the manual to major dialects. Another
recommendation was to simplify the language and use the more colloquial ‘Taglish’
(mixture of Tagalog and English) when appropriate, and translate modules to major
dialects. Stakeholders also suggested simplifying the modules teaching CBT principles
(reframing, thought substitution) because these were deemed too complex for the target
population.

Screening and assessment

The community-based treatment modules were intended for low- to mild-risk users.
However, stakeholders reported that there was a bottleneck because the Philippine law
stipulates that only government-accredited doctors are allowed to conduct drug
dependency evaluation. Given that there are fewer than 500 of these professionals in
the entire country, only a small percentage of recovering users have been screened and
assessed. This has led to many not being able to get the help they need in a timely
manner.

Capability of community facilitators

A concern raised by stakeholders was the lack of community facilitators to deliver the
modules. Although they reported having volunteers, particularly from church-based
organisations, the majority of these volunteers lacked the capability to facilitate.
Stakeholders noted that current programs tended to use lectures and do not focus on
skills development and adult-learning methodologies. They affirmed the need to provide
community facilitators with facilitation skills and to include simulation of the modules.
Given the lack of mental health professionals in their community, another concern was
the lack of personnel to monitor and coach community facilitators.

Safety and security

Given the presence of drug pushers in the community and the incidence of extra-judicial
killings, a concern raised by stakeholders was the safety of participants and facilitators.
Community leaders reinforced the importance of working with law enforcers to
safeguard the security of participants and facilitators. To mitigate this risk, the designers
added a checklist on the readiness of communities, which includes an assessment of
safety. The training also emphasises the importance of working with local government
units who can ensure the security of those involved in the program.

Discussion
This article describes the development of an evidence-informed, community-based drug
recovery intervention for low- to mild-risk illicit drug users in the Philippines. Using
McKleroy and colleagues’ (2006) MAP framework, the study highlights the value of
action research and employing a systematic process of adapting interventions to make
them more suited to a particular culture and context. In particular, the use of
participatory research provided valuable inputs in adapting, designing, and
implementing the intervention. Although the iterative process required more time, the
investment in the participatory research enhanced the relevance of the intervention.
The resulting intervention consisted of drug recovery skills and life skills. Although
these skills are not necessarily unique to Filipinos, the design of the modules reflect
important cultural and contextual nuances, including the use of small groups, interactive
and creative methodologies, and the use of music and prayer when appropriate. The
modules also considered Filipino cultural values such as the importance of family and
friends, the propensity for indirect communication, the desire not to offend family and
friends, and an interdependent self-construal.
Beyond the design of the intervention, the needs analysis suggests the importance
of community preparation and priming of potential participants. Based on the Stages of
Change Model (Prochaska, DiClemente, & Norcross, 1992), those who surrendered
appeared to be in the precontemplation stage and may not really see the need for
change. In addition, some use illicit drugs for productivity and rationalised it as
functional. Hence, low- to mild-risk users may need greater motivation to actually
participate in recovery intervention. This suggests that those involved in screening and
assessment may need to possess basic skills in motivation enhancement.
In addition, the ambivalence of low- and mild-risk users may be exacerbated by the
reluctance of Filipinos to seek professional help (Nadal, 2011; Tuliao et al., 2016). One
implication of this is the need to tap community healers and leaders who are the
preferred sources of help (e.g., Abe-Kim et al., 2004). The literature also suggests that
among Filipinos, health and mental health decisions are made with the family
(Nadal, 2011). This suggests that engaging and obtaining the support of family
members may be important in encouraging the participation of drug users.
The barriers cited by community stakeholders, such as the lack of training,
resistance from clients, clients’ limited cognitive ability, and the lack of resources are
similar to that faced in other developing countries (Amodeo et al., 2011). This highlights
the importance of investing in selecting and training of staff members to be more
culturally adept and develop effective skills in delivering these interventions.
Communities also need to provide resources for food and transportation, and consider
offering incentives for completion of the program, similar to CRA (Roozen et al., 2004).
Another concern was regarding the bottleneck in screening of users. Given that in
other countries, other health care professionals are allowed to conduct drug
dependency assessment (UNODC, 2014) suggests that current law may not have been
drafted with a public health perspective. There appears to be a need to revise the law
as well as increase the number of those who can do drug dependence evaluation.
The Philippine government's approach in criminalising illicit drug use and using fear
as a means to get people to stop is also not unique. Asian countries such as Vietnam,
China, Cambodia, Indonesia, Malaysia, and Thailand likewise adhere to the philosophy
of social re-education and force people who use illicit drugs into compulsory
rehabilitation (Vuong et al., 2017). However, the rise in extra-judicial killings and reports
that police receive cash rewards for executing drug suspects (Mogato & Baldwin, 2017)
is a critical factor that may affect the success of community-based programs. Some
participants and prospective facilitators expressed fear for their lives. If community
interventions are to succeed, it is important to ensure the safety of recovering users.
The issue of security is just as salient among volunteer community facilitators who may
think twice about being involved in working with illicit drug users out of fear for their own
safety.
As suggested by UNODC (2014), drug use is a complex phenomenon, and there is
a need for a holistic perspective on the issue of drug use. A study of community-based
drug recovery in China reports that a lack of coordination, divergent attitudes, and
conflicting targets for police and health officials undermine the shared goal of treatment
(Ma et al., 2016). This appears to true in the Philippines as well. The lack of recognition
of the national government on the many factors that lead to drug use (i.e., poverty, lack
of education, unemployment, poor parenting, poor coping skills) suggests the need to
educate government leaders and law enforcement officials on the bio-psychosocial
aspects of illicit drug use and the need for holistic, long-term and evidence-based
solutions.
Limitations of Research and Implications for Future Research
This study describes the development of an evidence-informed, community-based drug
treatment program. However, there is still a need for robust evaluation of the
effectiveness of the intervention. In addition, future studies may wish to explore what
factors may influence the effectiveness of the intervention, such as the background of
the facilitator, modality of module delivery, group constitution and size, among others.
The intervention was developed for low- to mild-risk adult users in the Philippines.
The needs analysis was also conducted only among urban poor drug users. Future
researchers may wish to validate whether the psychosocial needs of drug users in rural
areas and of other socio-economic classes are different. In addition, community
stakeholders also articulated the need for modules for children and youth.
Finally, the study focuses on addressing the psychosocial needs of illicit users.
There is emerging literature on the value of recovery support resources such as the role
of family and friends. Future studies may wish to examine how these, along with other
community resources, may influence the recovery of drug users.
Limitations notwithstanding, the study presents the process of adapting and
designing an evidence-informed community-based drug treatment intervention. It
highlights the importance of action-research as well as a participative process with
stakeholders in the development of interventions for the community.

Acknowledgments
The authors wish to acknowledge the Psychological Association of the Philippines,
Quezon City and the QC Anti-drug abuse council, the Archdiocese of Novaliches,
Novaliches Barangay Proper, Commission on Higher Education, United Nations Office
of Drug and Crime Philippine Office and all those who were involved in the needs
analysis and stakeholders consultations.

Endnotes
1 Barangay is the smallest unit of governance in the Phillipines.
2 ‘Tokhang’ is a Visayan word contraction of tuktuk hangyo, or to knock and plead.

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Filipinos, Colonial Mentality, and
Mental Health
E. J. R. David Ph.D.

Unseen and Unheard

A psychological approach to exploring the effects of colonialism

among Filipinos
Posted Nov 02, 2017

I was just in the Philippines recently, where I saw skin-whitening products and
clinics everywhere! It is also where I saw the pervasive vestiges of western
colonial influences, from the widespread use of English and the regard of it as
the language of the educated or upper class, to the abundance of western
restaurants and shops that make Manila seem more Americanized than many
places in America itself. All of these, of course, are remnants of the
Philippines’ long history of colonization under Spain and the United States. So
colonialism, and its most insidious legacy, colonial mentality, has been on my
mind.

And it seems like it has been on other Filipinos’ minds lately too. For instance,
the viral AJ+ video featuring Kristian Kabuay shows that his quest to revive
Baybayin is his attempt to restore and repair the immense cultural damages
that colonialism brought onto Filipinos. Also, Asia Jackson’s viral AJ+ video on
colorism and anti-dark skin attitudes among Filipinos touch on colonial
mentality as well. And even further, I definitely made sure I brought up colonial
mentality with major media executives and politicians while I was in the
Philippines, so it was at least temporarily in their minds.

So yes, colonial mentality—particularly skin-whitening—has been on many

Filipinos’ minds lately. But as Philippines Vice President Leny
Robredo acknowledged when I asked her about it, it’s a centuries-old issue,
and there’s been plenty of work on it, going as far back as Jose Rizal!
Indeed, many folks have documented and shared their painful stories,
struggles, confusions, and heartaches about colonial mentality throughout
the years.

And over the past 15 years, there has been some efforts to quantify and
“scientifically” capture colonial mentality among Filipinos. First, there’s
the Colonial Mentality Scale (CMS), which is a typical questionnaire that
directly asks people if they hold some signs of colonial mentality. The CMS
asks people to indicate their level of agreement or disagreement with
statements such as, “There are situations where I feel inferior because of my
ethnic background,” “There are situations where I feel ashamed of my ethnic
background,” "I would like to have a skin tone that is lighter than the skin tone
I have," “I make fun of, tease, or bad mouth Filipinos who speak English with
strong accents," and “Filipinos should be thankful to Spain and the United
States for transforming the Filipino ways of life into a White/European
American way of life." However, because people may easily lie, deny, or not
know too much about their own attitudes and behaviors to accurately report it,
I also developed the Colonial Mentality Implicit Association Test (CMIAT),
which attempts to capture whether Filipinos have strongly and automatically
associated Filipino culture with inferiority.

Although far from being complete and perfect, tools such as the CMS and
CMIAT have allowed us to attach some “numbers” to the very real stories that
people have been sharing for generations.

And so, what does the data tell us about colonial mentality among Filipinos?

Here’s an easily-accessible infographic summarizing some findings, and

below it are a few more details:
 Source: E.J.R. David

ARTICLE CONTINUES AFTER ADVERTISEMENT

Based on the CMS, there seem to be at least five indicators of CM among
Filipinos:

1. Feelings of inferiority for being Filipino;

2. Feelings of shame, embarrassment, resentment, or self-hate about being
a person of Filipino heritage;
3. Denigration of the Filipino body (regarding white physical characteristics
as more attractive, advantageous, and desirable than typical Filipino
physical traits such as brown skin and flat nose);
4. Discriminating against less-westernized Filipinos (e.g., making fun of
people from the provinces—“Promdi”—or indigenous peoples and regarding
them as “backward”); and
5. Tolerating or minimizing historical and contemporary oppression of
Filipinos (because such oppression is accepted as the appropriate cost of
civilization).
The CMS also allowed us to have an estimate on how common CM is among
Filipino Americans. When explicitly asked about colonial mentality,
approximately 30 percent of Filipino Americans admitted to having at least
one of the five “symptoms” of colonial mentality. Only around 1 percent
admitted feeling ashamed and embarrassed of their heritage, and 9.6 percent
admitted to feeling inferior for being Filipino. Only around 3.5 percent admitted
to discriminating against less-westernized Filipinos, and 10.5 percent admitted
to regarding Filipino physical traits as less desirable than white physical traits.
Finally, 16.4 percent admitted feeling fortunate for having been colonized and
feeling indebted to their past colonizers.

ARTICLE CONTINUES AFTER ADVERTISEMENT

However, when the CMIAT was used—a more subtle and less-direct way of
capturing CM—approximately 56 percent of Filipino Americans showed a
tendency to automatically associate inferiority with Filipino culture and
superiority with American culture. In addition to providing us with what is
probably a more accurate estimate of the prevalence of CM among Filipinos,
what the CMIAT studies also suggest is that CM may exist and operate
outside of our awareness, intention, or control. In other words, it seems as
though many of us may have internalized the oppression of our culture
and ethnicity so deeply that it now exists and affects us automatically.
And as previously mentioned, CM has existed for generations. So how is it
passed down intergenerationally? Research suggests that our peers, family,
and community seem to influence the development of CM among Filipino
Americans. Overall 96 percent of Filipino immigrants to the United States
report being exposed to Filipino inferiorizing messages while they were still
living in the Philippines. Specifically, 85 percent reported seeing CM from their
family, 88 percent from their friends, and 90 percent from their general
community. Perhaps the most egregious example of CM in the Philippines is
the abundance of skin-whitening products and clinics being advertised and
sold everywhere. And according to a survey conducted by Synovate
Philippines (2004, Skin Whitening in Southeast Asia), at least 50 percent of
Filipinos use skin-whitening products. Furthermore, recent research also
shows that skin-whitening use is most common among Filipinas, and among
the lower class and less-educated people in the Philippines.

Research also suggests that current experiences of racism are also related to

CM among Filipino Americans. That is, the more Filipino Americans
experience the denigration of their culture and ethnicity, the more likely they
are to develop CM. And research shows that 99 percent of Filipino Americans
report experiencing racism in the past year. Thus, it is very likely that many
Filipino Americans may hold CM.

ARTICLE CONTINUES AFTER ADVERTISEMENT

But so what if Filipinos have CM, and so what if they’ve had CM for
generations? Is having CM such a bad thing?

According to the World Health Organization, the use of skin-whitening has

been associated with mental and physical health damages. Overall, using
tools such as the CMS and the CMIAT, CM has been shown to relate to
poorer mental health. Specifically, it has been shown to be related to lower
levels of self-esteem, more depression symptoms, more anxiety symptoms, and
lower levels of life satisfaction. These correlates of CM are concerning as
research also shows that they typically co-occur with other troubling
conditions like alcohol and drug use, and poor school or job performance. So
yes, having CM is a bad thing.

Although we have continued to improve our understanding of CM, there are

still plenty more research questions that we need to explore concerning CM
and its implications. I truly hope that the tools we have now will make it easier
for us to engage in these explorations, and that more Filipinos will take up the
task of tackling these questions.
https://www.psychologytoday.com/us/blog/unseen-and-unheard/201711/filipinos-colonial-mentality-
and-mental-health
How I Learned To Talk To My Filipino Mom
About My Mental Health
It started with accepting just how different our life experiences have been.

November 22, 20187:30 AM ET

Heard on Morning Edition

MALAKA GHARIB
Twitter

Leonardo Santamaria for NPR

I was having a tough summer.

I was working a day job while writing a book, sometimes pulling 14-hour days. I felt overcome with guilt
when I wasn't working toward my deadline. I hardly had time to see friends. Most of my down time was spent
in an unhealthy way: scrolling through social media.

I was irritated, isolated and anxious. For the first time in my life, I started going to therapy, which was difficult
for me to admit to myself that I needed.

So I called the second most important person in the world (besides my husband): my mom. On the phone, I
listed all my woes, hoping to hear words of support.

She responded: "You don't need therapy. You're fine. Imagine what it was like for me."
She then recited the story I had heard so many times before. She came alone to this country from the
Philippines in the early 1980s. She raised my little sister and me as a single mom. She worked two jobs to
support us, including working grueling overnight shifts and holidays. Life was hard. Really hard.

She didn't think that what I was going through was a big deal. This absolutely crushed me. Whatever problems
I might have as her American-born daughter in the richest country on earth, they were nothing compared to
hers.

I left that conversation feeling like whatever I was going through was all in my head, and maybe I was — as
my mom mentioned on our phone call — "thinking too much."

Well, it certainly made me think. Why did my mom brush my problems aside? And I'm 32, an adult. Why did
her opinion matter so much? Why didn't she get it — get me?

Enlarge this image

The author Malaka Gharib and her mother Fleurdeliz San Pedro on a family trip to Paris in April.
Courtesy of Maro Mercene

It's hard for anyone to talk about mental health, especially to parents. But I wanted to know if there was
something about Filipino and immigrant culture that made things a little more complicated. So I turned to
Filipino-American researchers to help me try to see things from my mom's perspective — and understand my
own frustration.

I called E.J.R. David, a Filipino-American psychologist at the University of Alaska, Anchorage and told him
my story. He is the author of Brown Skin, White Minds, a book about Filipino-American psychology.
Please Tell Us What You Think About Shots
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to start the questionnaire.

It turns out Filipinos care a lot about what their family members think. Filipinos, he says, are some of the most
collectivistic people in the world. What that means, he says, is that "we don't just care about ourselves — we
are family-centered and our parents are a big part of our lives."

So, while mental health carries a societal stigma — or even shame — for everyone, "for Filipinos, that shame
is doubled," he says. "Not only do we not want to shame ourselves, we don't want to bring shame to our
family."

Some part of me must have anticipated that stigma, hence my own hesitation to jump into therapy. In
hindsight, I was probably looking for validation from my mom. Maybe if she was OK with it, then I'd be OK
with it, too.
"Getting approval from our parents is important so that they understand us. So that we know we're not bringing
our family shame," David explains.

That stigma may contribute to a startling picture of Filipino mental health in America. A 2015 review found
that Filipino-Americans have some of the highest rates of depression among Asian-Americans. Another study
found that Filipino-American adolescent girls have some of the highest rates of suicidal thoughts in America.
Yet Filipino-Americans across the board seek mental health treatment at some of the lowest rates.

CODE SWITCH
Filipino Americans: Blending Cultures, Redefining Race
That's why it's so important for young Filipino-Americans to talk to their parents about their struggles — and
to be understood, says Stephanie Balon, a Filipino-American youth and family therapist at the Daly City Youth
Health Center in California. "When there's a disconnect between parents and children, you can imagine how
isolating that can be."
Maybe it can help those in my generation see where our parents are coming from. It's not that they don't care,
but they have a very different experience.

For instance, my mom may have a different definition of what "hardship" means, says David, likely from her
own experience as an immigrant and growing up in a lower-income country — a common thread among many
immigrant cultures in the U.S.
She might also deal with stress and anxiety in a totally different way, says Balon. Balon interacts with young
Filipino-American patients and their parents at the youth center where she works.

While I sought treatment in the form of therapy, my mom might not have done the same. Filipino immigrants
have a hard time trusting traditional ideas of Western mental health and interventions like counseling and
drugs, says Balon. Instead, they may turn to religion — the clergy and prayer — to resolve their emotional
concerns. More than 80 percent of Filipinos are Roman Catholic, according to a 2015 government report from
the Philippines.
Cultural attitudes also come into play, for example, the old Tagalog saying, "bahala na."
"I was overhearing my parents talking about someone who had just passed away," says Balon. "I heard my dad
say, 'bahala na,' which is translated as – it's in God's hands. It'll work itself out. Many parents defer to that way
of thinking."
This sentiment can be traced back to the Philippines' history of colonization, says Kevin Nadal, author of a
book on Filipino-American psychology and a professor of psychology at John Jay College of Criminal Justice
at City University of New York.
For nearly 400 years, the Spanish ruled the country, followed by half a century of American occupation. "For
years, Filipinos were told what to do and to accept it," he says. "So dealing with the cards we were dealt — it's
a coping mechanism."

Nadal had another theory of the disconnect between me and my mom. Maybe it comes from growing up on
American TV, he suggested. I thought about Rory and Lorelai's close relationship on the Gilmore Girls. Who
didn't want that?
"For Filipino-Americans, there's this desire of what child-parent relationships could be like, from what they've
seen from TV and non-Filipino friends: communicative," says Nadal. In the Philippines, parents and kids have
a more formal relationship, he adds.

So there I had it, for the most part: the answers to my questions.

I can't blame my mom for her reaction. She just has a really different view of mental health — what it means
and how to treat it. And by caring so much about what she thought, I was just being a dutiful Filipino daughter,
concerned about my her and my family's reputation; but also a dutiful American one: hoping to foster a more
open relationship.

I told my mom what I'd learned. She agreed with pretty much all the researchers' points — except the last one.
She could talk to Nanay, my grandma, about anything, she told me. In high school, she had a terrible breakup
with her boyfriend and cried for a whole month. She remembers that her mom helped her get through it.

So I tried again. I asked her, why didn't she take my troubles seriously when I told her about them this
summer?

She was scared, she said, "that I didn't make you strong enough to stand on your own."

"I wanted you to think, maybe, that you could overcome it," she added. "That this was only a temporary
situation."

They were lovely words, words I needed to hear from my mother.

I just wish, I told her, you could have said them to me then.
https://www.npr.org/sections/health-shots/2018/11/22/669960524/how-i-learned-to-talk-to-my-
filipino-mom-about-my-mental-health