Breaking the Stigma in Counseling

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April 16, 2021

Writer/s: Angelica Jane Evangelista, Azie Marie Libanan
Researcher/s: Alvin Joseph Mapoy, K Ballesteros
Graphics: Bee Fukomoto
Moderators: Angelica Jane Evangelista, Azie Marie Libanan, Alvin Joseph Mapoy

 

Mental illness is the third most common disability in the Philippines (Martinez, 2020). According to the Philippine World Health Organization (WHO), Special Initiative for Mental Health conducted in the early part of 2020, at least 3.6 million Filipinos suffer from one kind of mental, neurological, and substance use disorder (DOH, 2020).

On a larger scale, mental and behavioral disorders account for about 14% of the global burden of disease, which means that as many as 450 million people suffer from these illnesses worldwide (DOH, 2020).

And with a pandemic suddenly taking the whole world by storm, the mental health of groups especially the older adults, health care providers, and people with underlying health conditions have suffered further and even more gravely (DOH, 2020).

As talked about in #UsapTayo’s March 20, 2021 twitter discussions, we have seen how Burnout and Pandemic Fatigue have been relevant consequences of the current global health crisis caused by COVID-19. The global community continues to suffer sustained and heightened feelings of distress from multiple stressors for over a year now (Recovering, 2021).

Despite these reports highlighting the prevalence of Mental Health related concerns and problems, and shared pandemic fatigue, a lot of people still choose to go untreated (at least professionally). There is still a generally low percentage of Filipinos seeking professional help, and accessing mental health services in the country. Such reluctance, according to a narrative synthesis of 15 related studies, is found to be influenced heavily by various psychosocial, socio-cultural, systemic/structural, and economic factors (Martinez, 2020).

Mental Health and Policy Support

With the passage of RA No. 11036, otherwise known as the Mental Health Act, in June of 2018, after a long policy campaign, there was considerable hope that the said law will promote the importance of Mental Health to educational institutions, workplaces, and communities, and protect the rights of those who are experiencing mental health illness against discrimination. The law was also expected to guarantee access to comprehensive and integrated mental health services, particularly for the marginalized and the most vulnerable (WHO, 2018).

This was supported by the subsequent passage of the Universal Health Care Law, in February of 2019, which mandated structural and functional changes in health financing, service delivery, and governance. The Philippine UHC Law sought to address the inequities faced by the country’s health system because of fragmented service delivery and inefficient financing mechanisms (UHC, 2019).

Before these laws, the move to professionalize the Guidance & Counseling, and Psychology practice in the country has also been vigorously undertaken. The Guidance and Counseling Act of 2004 (R.A. No. 9258), and the Philippine Psychology Act of 2009 (R.A. No. 10029) recognized the important role of guidance and counselors, and psychologists in nation-building and development.

RA 10029 further acknowledged the diverse specializations of psychologists and the diverse functions specific to the varied specializations. It also recognized the significance of the psychological services that practicing psychologists provide to diverse types of clients. The act highlighted the need to protect the public by preventing inexperienced or untrained individuals from offering psychological services (Psychology, 2010).

With all of these laws in place, what and where are the gaps that are reflected in data from quantitative community studies? Said data showed that the rates of formal help-seeking behaviors among the Filipino general population only ranged from 2.2% to 17.5%. This was supported by reports from qualitative studies where participants did not seek help at all (Martinez, 2020).

The frequency of reports of formal help seeking from studies conducted in crisis centers and online counseling, however, tended to be higher. For instance, the rate of engagement in online counseling among overseas Filipinos was 10.68%, those receiving treatment in crisis centers was 39.32%, while 100% of participants who were victims of intimate partner violence were already receiving help from a women’s support agency (Martinez, 2020).

The rate of formal psychological help-seeking of Filipinos overseas ranged from 2.2% of Filipino Americans to 17.5% of Filipinos in Israel. And both local and overseas Filipinos indicated that professional help is sought only as a last resort because they were more inclined to get help from family and friends or lay network (Martinez, 2020).

Counseling

According to the American Counseling Association, counseling is defined as a professional relationship that empowers diverse individuals, families, and groups to accomplish mental health, wellness, education, and career goals. Counseling is usually done by a mental health professional to help and guide people during difficult situations, such as the stress that comes from our daily lives (What is, n.d.).

It may also be a form of professional assistance in coping with personal problems, including emotional, behavioral, vocational, marital, educational, rehabilitation, and life-stage (e.g., retirement) problems. The counselor makes use of techniques such as active listening, guidance, advice, discussion, clarification, and the administration of tests (VandenBos, 2015).

 Counseling in the Philippines

“Much like its inherent multiculturalism, counseling in the Philippines has evolved from multiple influences. Counseling encompasses a broad spectrum of disciplines (e.g., guidance and counseling, counseling/clinical psychology), and an acknowledgment of the societal context in which it occurs (e.g., poverty, physical disasters, overseas working, graft and corruption, and economic and political instability) (Tuason, 2012)”

In this case, counselors must navigate societal stigmas regarding the need for mental health assistance and widespread ignorance of the field; they also advocate for mental health and resilience in difficult life circumstances (Tuason, 2012).

At present, there is a shortage of mental health professionals in the country. The ratio of Mental health professionals is 2-3 per 100,000 population (WHO & Department of Health, 2006) and more recent data indicate that there are 1.08 mental health beds in general hospitals and 4.95 beds in psychiatric hospitals per 100 000 of the population (WHO, 2014).

There are 46 outpatient facilities (0.05/100 000 population) and 4 community residential facilities (0.02/100 000) (WHO, 2014). Also, there are only tertiary care psychiatric hospitals here in the Philippines, some of which are the National Center for Mental Health (NCMH) which is located in Mandaluyong City, and Mariveles Mental Hospital in Bataan. The others are small satellites affiliated with the National Center of Mental Health.

Barriers on Help-seeking Behaviors

Stigma regarding mental health illness, more specifically towards seeking professional help or counseling, remains among the most cited reasons why people do not seek mental health treatment (Corrigan, 2004). Stigmatic belief held by self and others may be due to a variety of reasons such as lack of knowledge about mental health, and avoidance behavior towards individuals who suffer from mental health problems. (Vogel, Wester, & Larson, 2007),

Vogel, Wade, and Hackler (2007) suggest that the fear and anxiety of the undesirable label placed on the individual who are experiencing mental health difficulties, and the strong stigma about mental health illness in general, may be the reasons one will choose to be in denial regarding their mental health issues. This in turn, prevents them from seeking professional help.

Vogel, Wade, and Hackler (2007) also state that public opinion and public stigma play a powerful role in influencing someone about the stigma and the acceptance of mental health illness in the society. 

In the Philippines, themes on barriers and facilitators of formal help-seeking have been identified as:

  1. psychosocial barriers/ facilitators, which include social support from family and friends, perceived severity of mental illness, awareness of mental health issues, self-stigmatizing beliefs, treatment fears, and other individual concerns;
  2. socio-cultural barriers/facilitators, which include the perceived social norms and beliefs on mental health, social stigma, the influence of religious beliefs, and language and acculturation factors; and
  3. systemic/structural and economic barriers/facilitators, which include financial or employment status, the health care system and its accessibility, availability and affordability, and ethnicity, nativity, or immigration status (Martinez, 2020).

Specifically, the most commonly endorsed barriers were:

  1. financial constraints due to high cost of service, lack of health insurance, or precarious employment condition;
  2. self-stigma, with associated fear of negative judgment, sense of shame, embarrassment and being a disgrace, fear of being labeled as ‘crazy’, self-blame and concern for the loss of face; and
  3. social stigma that puts the family’s reputation at stake or places one’s cultural group in bad light (Martinez, 2020). 

Breaking the Stigma about Counseling

A most important point to emphasize is that advocacy should be directed toward societal issues and include a social justice agenda given the prevalent poverty, the intersection of poverty with crime and trauma, the necessity of overseas working in families, the presence of street children, and child laborers. These sectors have been worst hit by the current pandemic. These issues contribute to the context of the Filipino’s environment, and importantly, set the parameters for how change happens. Of these, the most significant are poverty, overseas working, and unstable political and economic conditions (Tuason, 2012).

Social issues become counseling issues at the individual level (CIA, 2011). Hazards and disasters in the Philippines also exacerbate the impact of poverty as the country is regularly affected by typhoons, volcanoes, landslides, earthquakes, and tsunamis (Tuason, 2012).

“Sociopolitical crises due to unstable political leadership and extreme socioeconomic inequities stress Filipino families” (Carandang, 1989). Furthermore, because of rampant graft and corruption in government offices, and dishonesty in the media, a collective and personal sense of volition is difficult to achieve. One problem is that the absence of consequences makes it hard for people to be accountable and to realize the consequences of their actions. Another is that people feel helpless in the face of power inequality and inequity of rights and duties (de Guzman, 2009). Hence, the sense of control is lacking, which is a necessary variable for change in counseling (Tuason, 2012).”

However, the country is still rich in resources that play a significant role in the counseling process, which strongly contribute to healing and flourishing. These include religiousness and spirituality (Dy-Liacco, Piedmont, Murray-Swank, Rodgerson,& Sherman, 2009); engagement of family members and friends (Grimm, Church, Katigbak, & Reyes, 1999); and a strong drive for survival, hopefulness, and hardiness (Tuason, 2012).”

Counseling practices, and research, training, and supervision of future counselors, therefore, will need to focus on restructuring societal systems to be more reliable and equitable. This is necessary to address the  deep conflicts perpetrated by long-standing graft and corruption, bribery, and injustices toward the citizens, the protracted conflict between Christians and Muslims (Ebal, 2006), exacerbated by intractable poverty. At the individual level, counselors will need to focus on redefining themselves within the context of the system to be empowered and to be able to create changes within their spheres of influence (Tuason, 2012).

With the indigenization of theories that started with Filipino psychology by Enriquez (1977) and phenomena of religion, consciousness, and culture by Bulatao (1992) the thrust for counseling models and theories in the future will be for specifically identifying, labeling, and using counseling models borne in Philippine society (e.g., Ramos, 2010; Tanalega, 2004).

Kapwa and Filipino help-seeking behaviors

Most of the studies identified informal help through family and friends as the most widely utilized source of support, while professional service providers were only used as a last resort (Martinez, 2020).

This is very culturally true for Filipinos. Studies have shown that reliance on, and accessibility of sympathetic, reliable and trusted family and friends may be a strong decision point in formal help-seeking behavior since professional help is sought only in the absence of this social support (Martinez, 2020).

This is consistent with the predominant cultural value that govern Filipino interpersonal relationships called “kapwa”  (or shared identity) in which trusted family and friends are considered as “hindi-ibang-tao” (one-of-us/insider), while doctors or professionals are seen as “ibang-tao” (outsider) (Martinez, 2020).

Filipinos are apt to disclose and be more open and honest about their mental illness to those whom they consider as “hindi-ibang-tao” (insider) as against those who are “ibang-tao” (outsider), hence their preference for family members and close friends as a source of informal help  (Martinez, 2020).

This may be a complexity in the Filipino help seeking behavior that we always need to keep in mind. Especially as we aim for the indigenization of theories and professional practice, which recognizes fully the phenomena of religion, consciousness, and culture  (Martinez, 2020).

In addition, Sydney-Based Psychologist Aimee Santos, stated that some Filipino values we see as positive traits can have a counter effect on one’s mental health, especially their help seeking behavior. 

One of the Filipino traits Aimee discusses is “hiya”. Many Filipinos see “hiya” as a sign of humility, but “hiya” can restrain individuals from expressing themselves and prevent them from seeking professional help. The aphorism “mahiya ka naman” (shame on you) is used to regulate  behavior to become more acceptable to our family and community, which may also prevent individuals from seeking help.

So for us to be “kapwa” when a friend or relative may come to us for some form of support, here are some Active Listening Reminders that you might want to keep in mind when dealing with people especially in highly charged situations or in this pandemic in general (Basic, 2019):

Active Listening Reminders
(Basic, 2019)

  • Take time to listen carefully, concentrate on what is being said
  • Telling their story will often help people understand, and eventually, accept the event.
  • Do not hurry
  • Ask questions to clarify
  • Try not to interrupt until story ends
  • Do ask questions to clarify
  • Occasionally restate part of the story in your own words to make sure you understand
  • Avoid Why/Why not?
  • Don’t judge
  • Avoid “I know how you feel.”
  • Avoid evaluation of their experience and their reactions
  • Silence is O.K. 

Helping Responsibly, Four Main Points:
(Basic, 2019)

  1. Respect safety, dignity and rights
  1. Adapt what you do to take account of the person’s culture
  2. Be aware of other emergency response measures
  3. Look after yourself.

What to avoid
(Basic, 2019)

  • Force people to share their story with you
  • Tell people what they should or should not feel or think
  • Minimize what they have gone through
  • Automatically assume they share your religious belief
  • Do not make assumptions about what survivors are experiencing or what they have been through
  • Do not assume that everyone exposed to a disaster /experienced a crisis will be traumatized
  • Do not pathologize
  • Do not talk down or patronize
  • Do not assume that all persons want to talk or need to talk to you
  • Do not give promises you cannot keep
  • Do not preach
  • Do not judge
  • Avoid taking more responsibility for the situation than seems appropriate

It is also important to Listen to what the person is NOT saying, and Provide Practical Help. And essentially, we always go back to every helping professional’s ethical compass in providing help– Primum Non Nocere: First, Do No Harm (Basic, 2019). #HelpIsHere 

Here’s the link to the #MentalHealthPH Directory of Mental Health Services: https://mentalhealthph.org/directory/

Join us on our tweetchat this Tuesday, April 20. Let’s talk about breaking the stigma on counseling! Tara, #UsapTayo!

Questions:

  1. How can we contribute to lessen the stigma surrounding counseling and seeking help from professionals?
  2. What are the barriers that discourage or prevent people from seeking professional help and accessing mental health services? How can we motivate people to seek help and access these services?
  3. What can you say to those who are hesitant/ or are unable to seek help?

Works Cited

An Introduction to the Philippine Universal Health Care Law. Retrieved from: https://thinkwell.global/wp-content/uploads/2020/05/PH-UHC-Law-Series_Brief-1.pdf

Basic Mental Health and Psychological First Aid in the School and Workplace. PFA notes. Retrieved from: www.argaocenter.com , www.smartereone.ph. May 2019

Lally, J., Samaniego, R.M., Tully, J. Mental health legislation in the Philippines: Philippine Mental Health Act. BJPsych Int. 16(3): 65–67. (2019). doi: 10.1192/bji.2018.33 PMCID: PMC6646847 PMID: 31385981. Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6646847/

Martinez, A.B., Co, M., Lau, J. et al. Filipino help-seeking for mental health problems and associated barriers and facilitators: a systematic review. Soc Psychiatry Psychiatr Epidemiol 55, 1397–1413 (2020). https://doi.org/10.1007/s00127-020-01937-2

Psychology – Professional Regulation Commission. (2010) Retrieved from: https://www.prc.gov.ph/sites/default/files/Psychology%20-%20Board%20Law_0.pdf 2010

Recovering from Pandemic Burnout. (2021). Ballesteros, K., #MentalHealthPH. Retrieved from: https://mentalhealthph.org/03-20/

Tuason, M.T.G., Fernandez, K.T.G., Catipon, M.A.D.P. , Trivino‐De, L., Arellano‐Carandang, M.L. Counseling in the Philippines: Past, Present, and Future (2012). https://doi.org/10.1002/j.1556-6676.2012.00047.x. Retrieved from: https://www.researchgate.net/publication/263731178_Counseling_in_the_Philippines_Past_Present_and_Future

UHC Act in the Philippines: a new dawn for health care. Retrieved from: https://www.who.int/philippines/news/feature-stories/detail/uhc-act-in-the-philippines-a-new-dawn-for-health-care 14 March 2019

VandenBos, G. R. (Ed.). (2015). APA Dictionary of Psychology (2nd ed.). American Psychological Association. https://doi.org/10.1037/14646-000

What is Professional Counseling? Retrieved from: https://www.counseling.org/aca-community/learn-about-counseling/what-is-counseling#:~:text=Professional%20counseling%20is%20a%20professional,challenges%20that%20they%20are%20facing.

WHO congratulates the Philippines on its new Mental Health Act. Retrieved from: https://www.who.int/philippines/news/detail/22-06-2018-who-congratulates-the-philippines-on-its-new-mental-health-act 22 June 2018 News release Manila, Philippines

How your Filipino Values can affect your Mental Heath. Retrived from: SBS Language | How your Filipino values can affect your mental health

Your Mind Matters: DOH Calls for unified response to Mental Health. Retrieved from: https://doh.gov.ph/press-release/YOUR-MIND-MATTERS-DOH-CALLS-FOR-UNIFIED-RESPONSE-TO-MENTAL-HEALTH Press Release | 10 October 2020

Other links:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6646843/

https://www.sfasu.edu/counselingservices/182.asp

https://link.springer.com/article/10.1007/s00127-020-01937-2

https://www.counseling.org/docs/default-source/vistas/stigma-toward-seeking-mental-health-services-among-graduate-counseling-students.pdf?sfvrsn=d4db432c_4

https://lawphil.net/statutes/repacts/ra2004/ra_9258_2004.html

https://doh.gov.ph/sites/default/files/health_advisory/IRR%20of%20RA%2011036.pdf

https://www.officialgazette.gov.ph/downloads/2019/02feb/20190220-RA-11223-RRD.pdf

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