Examining Expectations Among Polynesian Americans About Seeking Psychotherapy

Over the past several decades, abundant evidence (1–3) has suggested that many psychotherapies are effective and that the differences in outcomes among various forms of psychotherapy (e.g., cognitive-behavioral therapy, humanistic, psychodynamic) are generally small (4). Some common factors, such as the therapeutic alliance, have received substantial attention in the literature (5, 6), whereas others, such as client expectations, have received relatively less attention (7, 8).

Research (9–13) has shown, however, that clients’ expectations influence the process and outcome of psychotherapy. Client expectations about psychotherapy can be distilled into two prototypes: outcome expectations and process expectations (7). In regard to outcome expectations, clinical research (8, 11) suggests that clients who endorse more positive expectations of therapy have better treatment outcomes at termination.

In regard to psychotherapy process expectations, clients often enter therapy with preconceived notions regarding what psychotherapy is and how it should be conducted. If clients are not provided with information about the process of therapy and their role in it, then they may struggle to engage fully and may have difficulties with self-disclosure and with developing trust in their therapist (14, 15). Other expectations about the process of psychotherapy include whether clients expect to take charge of or lead the sessions or whether they expect the therapist to give them advice (16). These expectations may be experienced differently across diverse clients and issues.

Despite increased attention to multicultural characteristics of clients in psychotherapy, it is well documented that people from racial-ethnic minority groups tend to underuse counseling services and to end therapy prematurely (17–19). One such racial-ethnic minority group is Polynesian Americans, who mostly emigrated from the South Pacific islands (e.g., Tonga, Samoa) to the United States during the 1960s and 1970s (20). One explanation for underuse and high dropout rates among this and other minority populations is that traditional counseling approaches tend to reflect Western cultural values (21); therefore, counselors may not give adequate attention to important contextual factors such as race-ethnicity, gender, sexual orientation, and religion (22).

Although a majority of studies examining client expectations have centered on the experiences of those who espouse Western cultural values, some studies have examined the expectations of clients from specific racial-ethnic backgrounds (23–27). For example, Kunkel (28) found that level of acculturation influenced expectations of therapy among Mexican American college students and that approximately one-third as many of the Mexican American students had previous counseling experience compared with their White peers. Although research has examined specific client expectations of psychotherapy among racially diverse clients, the number of such studies is relatively sparse.

A particular racially diverse group in the United States that, to our knowledge, has not yet been examined regarding expectations of psychotherapy consists of individuals whose ethnicities derived from the Polynesian islands. This minoritized group is unique in that Polynesian Americans tend to emphasize communal and family structure as a way of survival, turning to religion for guidance and answers, and to family hierarchy (grandparents, parents, uncles, and aunties) as a cultural source of wisdom and direction.

Therefore, the aim of this study was to identify expectations of psychotherapy unique to Polynesian American clients. Specifically, we sought to examine the following: preferences about the gender and ethnicity of the therapist, how expectations about psychotherapy affect help-seeking behaviors, and possible mediating factors between psychotherapy expectations and attitudes about and intention to seek counseling. Other mediation-moderation variables have been examined with other Polynesian American samples. These variables have included mental health stigma and attitudes about seeking counseling (29), racial discrimination and satisfaction with life (30), parental acceptance and self-esteem (31), and religious commitment and psychological well-being (20). Our intent was to continue this body of research by examining whether audience- and advice-seeking behaviors mediated the association between psychotherapy expectations and attitudes about and intention to seek counseling in this sample of Polynesian Americans.

Thus, we investigated specific questions. What are the differences in preferences toward therapist gender and ethnicity? What are the differences across Polynesian ethnicities and genders related to attitudes about seeking professional psychological help and the intention to seek counseling? What are the differences in participant expectations regarding therapists providing advice (advice seeking) and clients leading sessions (audience seeking) across Polynesian American ethnicities and genders? Do Polynesian Americans’ expectations of therapists giving advice or clients taking charge of sessions significantly and positively correlate with client attitudes about and intentions to seek professional help? Do advice- and audience-seeking behaviors mediate the association between psychotherapy expectations and the intention to seek counseling?

Methods

Participants

After securing institutional review board approval, we recruited a community sample of Polynesian individuals across the United States. Individuals were invited to participate through social media, primarily Facebook, and asked to complete an anonymous web-based survey hosted by Qualtrics. Our research team, which consists of Polynesian Americans, used their Facebook profiles to post the link to the survey, inviting only their Polynesian American friends to participate. The participants gave their informed consent before participation and received $10 each as compensation for their time. For this study, Polynesian Americans were defined as individuals whose ethnicity derived from any of the islands in the Polynesian triangle (20).

Instruments

Attitudes Toward Seeking Professional Psychological Help Scale (ATSPPH).

The ATSPPH (32) is a 10-item scale revised from an original 29-item measure (33). This scale assesses people’s attitudes about seeking professional psychological help (e.g., “If I believed I was having a mental breakdown, my first inclination would be to get professional attention”). Items are scored from 1 (disagree) to 4 (agree); higher scores indicate more positive attitudes toward seeking professional help. The revised and original scales were significantly correlated (0.87), suggesting strong construct validity (32). Good internal consistency was found in the 10-item version, with a Cronbach’s alpha of 0.84 and 1-month test-retest reliability of 0.80 among college student samples. In a previous study with Polynesian Americans (29), the internal consistency of the 10-item version was 0.70. In the present study, Cronbach’s alpha for this measure was 0.75.

Milwaukee Psychotherapy Expectations Questionnaire (MPEQ).

The MPEQ is a 13-item scale, ranging from 0 (not at all) to 10 (very much so), developed to measure clients’ expectations about the components and effects of therapy (34). There are two dimensions: process expectations (expectations during the sessions) and outcome expectations (expectations following the sessions). Process items include “I expect my therapist will provide support” and “My therapist will provide me feedback.” Outcome items include “After therapy, I will have the strength needed to avoid feelings of distress in the future” and “Therapy will provide me with an increased level of self-respect.” The MPEQ has demonstrated good internal consistency (Cronbach’s α=0.90) and test-retest reliability (0.83) (34). Cronbach’s alpha for this measure with our sample of Polynesian Americans was 0.96.

Psychotherapy Expectancy Inventory–Revised.

The Psychotherapy Expectancy Inventory–Revised is a 30-item multidimensional inventory assessing expectancy effects for psychotherapy (16). In the present study, the advice-seeking and audience-seeking subscales were used to investigate the research questions. The advice-seeking subscale is a six-item measure, ranging from 1 (not at all) to 7 (strong). This subscale assesses the extent to which clients expect to receive advice from their therapists. Items include “How strongly do you expect to get definite advice from your therapist?” and “How strongly do you expect your therapist to suggest what you should do about your problem?” The advice-seeking subscale yielded a high internal consistency estimate of 0.87 and a test-retest reliability of 0.85. Cronbach’s alpha for this subscale was 0.88 for this study. Given research on psychotherapy among Polynesian Americans (29, 35) and on the Polynesian American cultural context (35), receiving advice may be an essential factor related to positive processes and outcomes of psychotherapy for Polynesian Americans.

The audience-seeking subscale is a six-item measure, ranging from 1 (not at all) to 7 (strong). This subscale assesses whether clients expect to take control of and lead the sessions. Items include “How strongly do you expect to initiate the conversation?” “How strongly do you expect to feel as though you [are] ‘in charge’ of the hour?” and “How strongly do you expect to initiate the conversation?” This subscale yielded a high internal consistency estimate of 0.87 and a test-retest reliability of 0.85. Cronbach’s alpha for the subscale was 0.90 in this study. As shown in psychotherapy research among Polynesian Americans and within the Polynesian American cultural context (29, 35), audience seeking may be an essential factor related to positive processes and outcomes of psychotherapy for this population.

Intentions to Seek Counseling Inventory (ISCI).

The ISCI (36) is a 17-item scale, ranging from 1 (very unlikely) to 6 (very likely), that measures the intent to seek psychological services for a list of specific problems, including relationship difficulties, depression, personal worries, and drug problems. There are three subscales assessing specific dimensions: psychological and interpersonal concerns, academic concerns, and substance use concerns. Responses on the ISCI are summed, with higher scores indicating a greater likelihood of seeking services for that issue. The measure has been found to detect differences in individuals’ intentions to seek psychological services (36). The ISCI has adequate internal consistency estimates (0.90). Cronbach’s alphas for the inventory in this study were 0.90, 0.80, and 0.84 for the psychological and interpersonal concerns, academic concerns, and drug use concerns subscales, respectively.

Results

The sample consisted of 593 Polynesian Americans (65% women [N=385] and 35% men [N=208]). The sample was 36% (N=213) Native Hawaiian, 24% (N=142) Samoan, 14% (N=83) Tongan, 4% (N=23) Fijian, 2% (N=11) Niuean, 2% (N=11) Māori, 1% (N=4) Tahitian, and 18% (N=106) multiethnic Polynesian heritage. Participant age ranged from 18 to 73 years; mean±SD age was 27±10.9. Sixty percent (N=355) of the sample reported belonging to the Church of Jesus Christ of Latter-day Saints. The balance of the sample was 12% (N=71) Catholic, 5% (N=29) Protestant, 2% (N=11) Evangelical, 2% (N=11) Buddhist, 2% (N=11) Baptist, 1% (N=5) Muslim, and 17% (N=100) “other.” Fifty-one percent (N=302) of the participants indicated they would prefer to see a Polynesian therapist, 27% (N=161) indicated they would prefer to see a non-Polynesian therapist, and 22% (N=130) reported no preference (“it doesn’t matter”). Fifty-eight percent (N=344) indicated they would like to see a female therapist and 42% (N=249) reported wanting to see a male therapist.

Gender Preference

We examined group differences in preference for psychotherapist gender. Chi-square analyses indicated that a significantly higher percentage of men reported preferring a male therapist (63% [N=374], preferred female therapist=22% [N=219]), whereas a significantly higher percentage of women reported preferring a female therapist (78% [N=462], preferred male therapist=37% [N=131]; Pearson chi-square=78, df=1, asymptotic p=0.001).

Attitudes Toward and Intention to Seek Professional Help

There were no significant differences among the Polynesian American ethnicities in attitudes toward seeking professional psychological help (ATSPPH; F=1.70, df=2), nor were significant differences found among the Polynesian American ethnicities in intention to seek counseling for psychological and interpersonal concerns (ISCI; F=1.31, df=2). There was a significant difference among the Polynesian American ethnicities in intention to seek counseling for academic concerns (F=3.10, df=2, p<0.01). Post hoc comparisons indicated that Native Hawaiians and Tongans differed significantly from each other (Tukey’s honest significant difference=2.70, SD=0.78, p=0.010), with the Native Hawaiians demonstrating a group mean of 10 and the Tongan group demonstrating a group mean of 13, indicating that Tongans were more likely to seek professional help for academic concerns than Native Hawaiians. In addition, significant differences were seen across the two genders in attitudes toward seeking professional help (mean score for women=27, mean score for men=25; F=21, df=2, p<0.01). No significant gender differences were seen in intention to seek counseling for psychological and interpersonal concerns (F=1.60, df=2) or for academic concerns (F=1.53, df=2).

Advice- and Audience-Seeking Behaviors and Expectations of Psychotherapy

No significant differences were found among the Polynesian American ethnicities for expectations regarding the process or outcomes of psychotherapy (MPEQ; F=0.84, df=2; F=0.67, df=2) or for expectations regarding advice seeking (F=1.50, df=2). However, women and men demonstrated significant differences in expectations about the process of psychotherapy (mean MPEQ=86 for women and 79 for men, F=7.70, df=2, p<0.010) and in expectations about psychotherapy outcomes (mean MPEQ=36 for women and 34 for men, F=4.00, df=2, p=0.020). No significant differences were observed between the two genders for advice seeking (F=0.00, df=2), among the Polynesian American ethnicities for expectations regarding psychotherapy and audience seeking (F=0.80, df=2), or between gender groups for expectations regarding psychotherapy and audience seeking (F=3.77, df=2).

Correlational Analysis

A correlation analysis among variables was conducted (see Table 1). Results showed a weak but statistically significant positive correlation between audience-seeking behavior (but no statistically significant correlation with advice-seeking behavior) and attitudes toward seeking professional psychological help. However, audience-seeking and advice-seeking behaviors were found to be statistically significantly and positively correlated with intention to seek counseling for psychological concerns (advice seeking, r=0.180; audience seeking, r=0.210), academic concerns (advice seeking, r=0.240; audience seeking, r=0.300), and problematic substance use (advice seeking, r=0.160; audience seeking, r=0.060).

Indirect Effects

Both audience seeking and advice seeking were examined as mediators between psychotherapy expectations and intention to seek counseling. We used ordinary least-squares techniques in Hayes’ (37) PROCESS macro for SPSS, version 3.4, to estimate regression coefficients for each main and indirect (mediating) effect. Bootstrapping techniques allow researchers to test results by using multiple iterations of resampling, with replacement from the available sample (37). We used 10,000 bootstrapped sampling iterations, with replacement, to generate parameter estimates with bias-corrected 95% confidence intervals (CIs) to assess significance. Parameter estimates that did not have a bias-corrected 95% CI range that included zero were considered statistically significant at an alpha of 0.05. Four models were examined, with seeking behaviors (i.e., audience seeking and advice seeking) as the two mediators, expectations (process or outcome) as the independent variables, and intention to seek counseling (for psychological and interpersonal concerns or for academic concerns) as the dependent variables.

Audience-seeking behaviors significantly mediated the associations in all four models when the analyses were controlled for the effect of advice seeking. In model 1, bootstrapping results showed that audience seeking significantly mediated the association between psychotherapy process expectations and intention to seek professional help for psychological and interpersonal concerns (95% CI=0.01–0.05; indirect effect=0.27, SE=0.10, t=3.10, df=1, p=0.001; direct effect=0.06, SE=0.04, t=1.80, df=1, p=0.065) (Table 2). In model 2, audience seeking significantly mediated the association between psychotherapy process expectations and academic concerns (95% CI=0.01–0.03; indirect effect=0.20, SE=0.02, t=7.30, df=1, p=0.001; direct effect=0.00, SE=0.01, t=0.30, df=1) (Table 3). In model 3, audience seeking significantly mediated the association between outcome expectations and academic concerns (95% CI=0.02–0.07; indirect effect=0.17, SE=0.03, t=5.40, df=1, p<0.001; direct effect=0.03, SE=0.03, t=1.00, df=1) (Table 4). In contrast, audience seeking and advice seeking did not have significantly different indirect effect strengths (all bias-corrected 95% CIs included zero). Advice-seeking behavior did not significantly mediate any of the proposed associations (all bias-corrected 95% CIs included zero).

Discussion

We examined the link between psychotherapy expectations and intent to seek counseling among Polynesian American adults residing in the United States. Specifically, we sought to better understand the associations between attitudes toward seeking counseling, intent to seek counseling, and audience- and advice-seeking behaviors and expectations about psychotherapy process and outcome. These aspects of psychotherapy expectations are important common factors that have been less understood than traditionally examined factors, such as the therapeutic alliance, empathy, and goal consensus (34). Moreover, these expectations have been even less understood among Polynesian Americans (17).

We sought to better understand differences in preferences for having a psychotherapist of a certain gender among a sample of Polynesian American participants. Results suggested that the men significantly preferred to have a male therapist, whereas the women preferred to have a female therapist. These results may have been caused by gender preferences in emotional expression among Polynesian American men, who typically turn (or tend to prefer to turn) to other men for emotional support, connection, understanding, and empathy. Another explanation could be that, within Polynesian American families, open communication, fidelity, and respect for the opposite gender are important, and unrelated Polynesian men and women speaking to each other alone in an isolated environment may be considered inappropriate and disrespectful.

We examined the differences in attitudes about seeking counseling and intentions to seek professional help across Polynesian American ethnicities and genders. A significant difference was found between Native Hawaiians and Tongans for the intention to seek counseling, particularly for academic concerns. A possible explanation for this result could be that Native Hawaiians and their kingdom were overthrown, thus forcing an exposure to Western culture, including different mental health and educational systems, whereas most Tongans migrated to the United States by choice in search of better opportunities. Although few studies exist among Tongans in the United States regarding the above result, some research in New Zealand (38, 39) has shown that Tongans who experience less acculturation are more likely to struggle with academic concerns and poor mental health. We also found that Polynesian American women reported more positive attitudes toward seeking professional help than Polynesian American men, a finding consistent with previous research on Polynesian American women (29).

We explored differences in participant expectations regarding therapists giving advice (advice seeking) and clients leading the sessions (audience seeking) across Polynesian American ethnicities and genders. Although no significant differences were seen across Polynesian American ethnicities in advice seeking or audience seeking, the women scored higher than the men on expectations regarding the psychotherapy process and outcomes. One explanation is that Polynesian American women may have more positive attitudes about seeking psychotherapy (29), which may have increased their desire to improve and take interest in their own healing process.

We sought to understand whether Polynesian Americans’ expectations to take charge of the sessions and to receive advice from their therapists were positively correlated with attitudes about seeking professional help and intention to seek psychotherapy for certain problems. We found that intention to seek psychotherapy was positively correlated with the expectation to take charge during sessions and to receive advice from the therapist. The positive link between this sample of Polynesian Americans expecting to lead the sessions and intention to seek psychotherapy could appear as somewhat inconsistent with traditional Polynesian cultural values of deference and respect for authority figures (35). This finding could be interpreted as expecting to feel some ownership and empowerment during the sessions by initiating topics and feeling heard. It is certainly possible that these participants would expect to receive advice on and possible answers to their problems from their therapists if they were to seek psychotherapy. Seeking advice and helpful solutions toward their well-being and healing in session seem to be consistent with the Polynesian cultural context of deferring to authority and professional experts (35). Among most Polynesian cultures, a hierarchy status system related to seeking answers to life problems exists, based on age, title, and life experience. Many families within Polynesian cultures espouse this hierarchical community and family structure; information, knowledge, and wisdom are sought from those who are older, wiser, and have titles (e.g., parents, grandparents, or chiefs of the village) and full life experiences (29).

We investigated the impact of audience- and advice-seeking behaviors as mediators of expectations about the psychotherapy process and outcomes and on intent to seek psychotherapy. Results indicated that audience-seeking behaviors mediated the associations between psychotherapy process expectations and intent to seek counseling for psychological and interpersonal concerns as well as for academic concerns. Results also showed that audience-seeking behaviors mediated the association between psychotherapy outcome expectations and intent to seek counseling for academic concerns. This sample of Polynesian Americans may have been more likely to intend to seek psychotherapy if they felt they could be “in charge” of, initiate conversation in, and feel engaged during their therapy sessions.

Implications

First, this study may help psychotherapists working with Polynesian Americans attend to cultural and gender differences regarding psychotherapy process and outcome expectations of this population. Second, this sample showed a preference for counseling from psychotherapists of Polynesian ethnicities. Third, the participants preferred psychotherapists who matched their own gender, a result that may have been related to cultural values and norms regarding respect and appropriateness of interactions between the genders. Finally, the results showed that Polynesian American individuals may expect to take charge and lead therapy sessions. Knowledge of this expectation may help therapists in creating the therapeutic alliance. Moreover, therapists who are sensitive to cultural contexts when they engage in psychotherapy with Polynesian Americans, attend to Polynesian American cultural preferences regarding gender interactions, address process and outcome expectations of psychotherapy, and are attuned to the attitudes and intentions of this population in seeking counseling may increase the likelihood that Polynesian Americans will participate and develop trust in psychotherapy (17, 40, 41).

Limitations

This study had some limitations caused by the nature of the survey study design. First, a majority of the participants were of Native Hawaiian, Tongan, and Samoan descent, whereas only a small portion of Fijians, Niuean, Māori, and Tahitians were represented. The ratio of these subpopulations of Polynesian Americans was consistent with the percentage of these populations in the United States (17, 20, 29, 35). A large part of this sample of Polynesian Americans were members of the Church of Jesus Christ of Latter-day Saints (20). The results may not be generalizable across all Polynesian ethnicities. Also, a significant portion of the participants were social media friends of the researchers, which may have introduced participant bias. The study was a cross-sectional correlational study; hence, no causal statements can be made.

Conclusions

To meet the needs of this underserved population, the dearth of information regarding Polynesian Americans’ use and expectations of psychotherapy must be addressed. Psychotherapists who work with this population should seek to be attuned to ways they can better understand its preferences and expectations for psychotherapy.