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1 PUBLIC ATTITUDES TOWARD THERAPY FRAMED BY COMMON FACTORS AND SPECIFIC INGREDIENTS By LAWTON K. SWAN A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT OF THE REQUIREMENTS F OR THE DEGREE OF DOCTOR OF PHILOSOPHY UNIVERSITY OF FLORIDA 2013
2 2013 Lawton K. Swan
3 ACKNOWLEDGMENTS This dissertation would not have been possible without the wisdom and generous support of my doctoral advisor and committee c hair, Dr. Martin Heesacker, who deserves more accolades for his contributions than the scant few lines called for in this brief note of thanks will allow. Perhaps most importantly, he allowed me the creative space to develop and flourish as a scientist a mentoring decision for which I will be forever grateful I am similarly thankful for the sage guidance and encouragement of my full supervisory committee: Drs. Lise Abrams, John Chambers, Jamie Funderburk, and David Hackett. From each of these valuable me mbers I gleaned several insights which significantly improved the quality of this research. I also find myself indebted to numerous colleagues and friends who provided critical and candid feedback on my ideas In particular, the many conversations I shared with Lana Tolaymat and Taylor Locker shifted my thinking about psychotherapy science on multiple occasions. Finally, and essentially I thank my exceedingly meticulous and perceptive editor; my unconditionally supportive sounding board; my most loyal int ellectual ally; my most authentic critic; and my unending source of motivation and inspiration : I thank my wife,
4 TABLE OF CONTENTS page ACKNOWLEDGMENTS ................................ ................................ ................................ .. 3 LIST OF TABLES ................................ ................................ ................................ ............ 6 LIST OF FIGURES ................................ ................................ ................................ .......... 7 ABSTRACT ................................ ................................ ................................ ..................... 8 CHAPTER 1 INTRODUCTION ................................ ................................ ................................ .... 10 Research Aims and Hypotheses ................................ ................................ ............. 12 Implications ................................ ................................ ................................ ............. 15 2 STUDY 1 ................................ ................................ ................................ ................. 17 Overview ................................ ................................ ................................ ................. 17 Method ................................ ................................ ................................ .................... 17 Participants ................................ ................................ ................................ ....... 17 Materials and Proced ure ................................ ................................ .................. 18 Results ................................ ................................ ................................ .................... 21 Help Seeking ................................ ................................ ................................ .... 21 Stigma ................................ ................................ ................................ .............. 22 Discussion ................................ ................................ ................................ .............. 23 3 STUDY 2 ................................ ................................ ................................ ................. 27 Overview ................................ ................................ ................................ ................. 27 Personal Preference versus Recommendations for Others .............................. 27 Different Types of Mental Distress ................................ ................................ ... 30 Method ................................ ................................ ................................ .................... 30 Participants ................................ ................................ ................................ ....... 30 Materials and Procedure ................................ ................................ .................. 31 Results ................................ ................................ ................................ .................... 33 Replicating Study 1 ................................ ................................ .......................... 34 Exploratory Analyses ................................ ................................ ........................ 35 Personal preference versus reco mmendations for others .......................... 35 Different types of mental distress ................................ ............................... 36 Previous psychotherapy exposure ................................ ............................. 36 Expectations ................................ ................................ .............................. 37 Demand characteristics ................................ ................................ ............. 38 Discussion ................................ ................................ ................................ .............. 38
5 4 GENERAL DISCUSSION ................................ ................................ ....................... 45 A New Perspective ................................ ................................ ................................ 45 Limitations and Future Directions ................................ ................................ ........... 48 Conclusion ................................ ................................ ................................ .............. 51 APPENDIX A INFORMED CONSENT DOCUMENTS ................................ ................................ .. 52 B S ................................ ................................ ........ 56 C ................................ .................. 62 REFERENCES ................................ ................................ ................................ .............. 66 BI OGRAPHICAL SKETCH ................................ ................................ ............................ 73
6 LIST OF TABLES Table page 2 1 Study 1 s ample c haracteristics ( N = 98) ................................ ............................. 26 3 1 Study 2 s ample c haracteristics ( N = 375) ................................ ........................... 42
7 LIST OF FIGURES Figure page 3 1 N = 375) attitudes toward seeking two va rieties of psychotherapy one framed by common factors and framed one by specific ingredients for themselves or for others.. ................................ ......................... 43 3 2 Percentage of participants ( N = 375) who indicated that they would prefer psychotherapy framed by common factors, psychotherapy framed by specific ingredients, had no preference between the two, and preferred neither when considering seeking help for five different types of psychological distress. ........ 44
8 Abstract of Dissertation Presented to the Graduate School of the University of Florida in Partial Fulfillment of the Requirements for the Degree of Doctor of Philosophy PUBLIC ATTITUDES TOWARD THERAPY FRAMED BY C OMMON FACTORS AND SPECIFIC INGREDIENTS By Lawton K. Swan August 2013 Chair: Martin Heesacker Major: Psychology Psychotherapy scholars have devoted considerable attention to resolving the question of how psychotherapy works : d o specific psychological int erventions target distinct psychopathologies, or do the nonspecific factors common to all forms of therapy such as a compassionate therapist and a cogent rationale for treatment account for successful treatment outcomes? Despite decades of psychotherapy pr ocess and outcome research a clear answer has yet to emerge from the empirical data Among psychotherapy consumers however, recent evidence suggest s a marked preference for common factors relative to specific interventions The present st udies test ed the notion that the public preference for therapy framed by common factors stems in part from the belief that the alternative, therapy which focuses on treating pathology (specific ingredients), carries a relatively higher risk of social stigm atization TM service ( N = 98 ; Study 1 ) and SocialSci.com ( N = 375 ; Study 2 ) each rated their attitudes toward seeking two varieties of psychotherapy: one emphasizing nonspecific common factors, and one emp hasizing specific evid ence based therapy ingredients Consistent with prior research, a nalyses revealed an overall preference for therapy framed by common
9 factors erceptions of stigmatization by others for seeking each type o f therapy partially mediated this effect supporting the specific ingredients stigma model articulated in Chapter 1 Exploratory analyses revealed that therapy preferences depended on whether participants considered treatment for themselves or for another person, and on the type of psychological problem participants anticipated experiencing Implications for research and for campaigns attempting to improve public attitudes towa rd psychotherapy are discussed.
10 CHAPTER 1 INTRODUCTION In their widely cited 20 06 report on the nature and objectives of evidence based preferences when rendering therapeutic servic es. Although similar calls appeared in the psychological literature more than 40 years ago (e.g., Rosen, 1967), the empirical study of client preferences, defined as the behaviors or attributes of a therapist or therapy that clients desire (Glass, Arnkoff, & Shapiro, 2001), has burgeoned only recently. Consistent with assigned to psychotherapy congruent with their preferences whether for a particular type of therapist, t reatment modality, or the role clients are expected to play in session show lower rates of attrition and greater post treatment gains than their non matched counterparts (Swift & Callahan, 2009; see also Swift, Callahan, & Volmer, 2011 for a comprehensive review). Preferences likely exert their influence on treatment outcomes in conjunction with expectations (e.g., Greers & Rose, 2011), a related but conceptually distinct construct (Tracey & Dundon, 1998) describing the features of a therapist or therapy th at clients anticipate (Glass et al., 2001). Recently, Swift and Callahan (2010) nominated a new and potentially important preference dimension for study: the relative emphas e s practitioners place on empirically supported interventions versus nonspecific co mmon factors in therapy. This dimension mirrors a theoretical divide among scholars concerning the role of theoretically derived, specific techniques (e.g., systematically challenging the maladaptive thought patterns associated with depression) in effectiv e psychotherapy
11 (Wampold, 2001). Many regard these specific techniques as the active ingredients therapy requires to produce change. Therapy guided by this perspective, often deemed Elkins, 2009; Wampold, Ahn, & Coleman, 2001), proce eds by first empirically supported 2004, p. 873; see also Baker, McFall, & Shoham, 2009; Chambless & Ollendi ck, 2001 ; Hunsley & Di Giulio 2002 ). On the other hand, common factors theory (e.g., Frank & Frank, 1991; Hubble, Duncan, & Miller, 1999; Wampold, 2001) contends that the true to all efficacious approaches, such as a strong therapist client alliance and a cogent rationale for treatment (Messer & Wampold, 2002). Both positions offer conflicting answer s to the question of precisely how psychotherapy works (Elkins, 2009) both have attracted scores of loyal allies and vociferous opponents (Wampold, 2009), and both can ostensibly justify their views with the published psychotherapy process and outcome research ( Lilienfeld & Arkowitz, 2012 ) 1 Among scientists and scholars a clear win ner has yet to emerge Among psychotherapy consumers however, recent evidence suggests a marked preference for common factors. Swift and Callahan (2010) provided the first preliminary evidence that psychotherapy clients may place more value on therapeutic common factors such as a strong working relatio nship facilitated by a warm and experienced clinician than on an 1 and specific ingredients to treatment outcomes is beyond the scope of this dissertation, which will focus on consumer preference rath er than therapy effectiveness. For reviews of the controversy surrounding therapy effectiveness, see Cuijpers et al. (2008); Imel and Wampold (2008); Hunsley and Di Giulio ( 2002 ); and Wampold (2009). A dditionally, a slightly more thorough summary of the de begins Chapter 4.
12 of a university based clinic was willing to sacrific empirical support to ensure that the therapist delivering said intervention was relatable, empathetic, experienced, and likely to do more listening than talking in session. My own research suggests that this willingness to forfeit empirically established efficacy extends to an overall preference for therapy framed by common factors, even among those who have never experienced psychotherapy. In a within participant study of Amazon Mechanical Tur k TM ( 2013 2 ; abbreviated as MTurk TM hereafter ) users (Swan & H eesacker, 2013 ), my coauthor and I asked 329 adults from across the United States (60.2% female, mean age= 35.92) to rate their attitudes toward seeking two varieties of psychotherapy: one emphasizing nonspecific common factors 3 and one emphasizing specif ic evidence based therapy ingredients 4 Analyses revealed a pronounced ( d = .5 0 ) preference for therapy framed by common factors among previous clients and non clients alike indicating that potential clients may seek help more readily from providers who a ccentuate the nonspecific aspects of therapy. Research Aims and Hypotheses T ogether, these two studies suggest that campaigns to increase the utilization of mental health services may do well to stress the importance and presence of nonspecific common fact ors, rather than the scientific credibility of individual 2 Amazon Mechanical Turk TM is a registered trademark of Amazon.com, Inc. or its affiliates in the United States and/or other countries. 3 The description highlighting common factors read: There are many different varieties of effective psychoth erapy. Research has shown that they all work because of what they share in common: a space to freely talk about and work through your problems with a therapist you can trust. 4 The description highlighting specific ingredients read: Psychological treatments work just like taking medicine After assigning a diagnosis, your clinician can choose the correct therapy to fix your particular problem. Receiving the right evidence based treatment leads to the best outcomes.
13 interventions or techniques However, such a broad recommendation seems unwarranted on the basis of one sample of active clients in a single clinic and one sample of MTur k TM users replication with ind ependent samples and variation in research methods would bolster confidence in the generalizability of this apparent public preference for therapy framed by c ommon factors. first research aim was to conduct such a replication. Hypothesi s 1 predict ed that in two samples of adults from across the United States, participants would report more positive help seeking attitudes toward a description of psycho therapy framed by common factors relative to a similar description framed instead by sp ecific ingredients. To ensure that the effect is not limited to the particular wor dings I used in my prior research ( see footnotes one and two above ), I constructed entirely new descriptions for the present studies to capture the essential features of each model (Chapter 2). This dissertation ought to extend prior work by testing a theoretical explanation for th is discrepancy in attitudes Specifically, H ypothesis 2 predict ed that participants w ould view involvement in therapy guided by common factors as less stigmatizing than involvement in therapy guided by specific ingredients. This expectation is grounded in a robust literature documenting a reliable correlation between expecting stigmatization for participating in mental health se rvices on the one hand, and attitudes toward seeking professional psychological help on the other as perceptions of mental health treatment stigma increase, help seeking attitudes become more negative (see Vogel, Wade, & Hackler, 2007 for a review of this literature). Modified labeling theory (Link et al., 1989), which posits that awareness of societal devaluation discrimination toward the mentally ill leads to negative consequences for
14 esteem if they are labeled as having a mental illness, se rves as this dissertation major theoretical framework. According to this model, the threat of being classified as mentally ill when such treatment is likely to help alleviate suffering. Psych otherapy described primarily as the matching of specific techniques to particular diagnoses may therefore elicit higher levels of anticipated societal stigma for seeking treatment t han a description highlighting nonspecific and non pathology based elements Hypothesis 3 combine d H ypotheses 1 and 2 into a causal model, predicting that differences in perceptions of stigmatization for seeking each type of therapy (common factors versus specific ingredients) will mediate the relationship between psychotherapy f raming and help seeking attitudes. That is, H ypothesis 3 puts forward the notion that the public preference for therapy framed by common factors stems at least in part from the belief that therapy which focuses on treating pathology carries a relatively hi gher risk of incurring stigmatization (the specific ingredients stigm a model ) In our pr evious study of MTurk TM users seeking attitudes (Swan & Heesacker, 2013 ), my coauthor and I selected ten individual difference constructs to explore as potential pr 5 Each seemed to hold some promise in answering the question of who is more likely to prefer the common factors or specific ingredients approaches t o psychotherapy. For instance, we suspected that those with a high need for closure, external locus of control, and a tendency to submit to authority would desire structured intervention s targeting clearly 5 tendency to submit to authority, need for closure, locus of control, comfort with emotions, current level of psychological distress, gender, and belief in the role of genetics in precipitating mental illness. A recent unpublished study also similarly failed to find a significant moderating effect of adult attach ment style (King, Swan, & Heesacker, 2013).
15 defined problem s (diagnose s). To the contrary, the vast majority of these variables failed to predict attitudes toward either type of therapy only having previous experience with psychotherapy and feeling that science makes our way of life change too quickly emerged as significant participant level pr edictors (both were positively associated with a preference for co mmon factors) Rather than continuing to focus on internal (dispositional, attitudinal) participant factors that might predict therapy preference s this dissertation third exploratory research aim was to investigate the influence of two external (social situational) factors : (a) the possible discrepancy would recommend to another; and (b) the particular psychological problem that one anticipates experiencing ( depression anxiety, eating disorders substance abuse or thought dis turbances) The theoretical rationales for exploring these factors are presented in the introductory section of Chapter 3. Implications In practice, clients may not face a dichotomous choice betwe en therapies guided exclusively by specific or nonspecific factors. This dissertation aims only to test the notion that the relative emphases placed on each meta theory when describing the gist of tr eatment to the public matters. Many potential clients hav e likely been exposed to the idea that therapists differ in their use of empirically supported interventions, and to a debate amongst scholars of psychotherapy concerning the question of whether the only scientific approach to psychotherapy is one based on the medical model (e.g., Abbot, 2009; Palca, 2009). Consider for instance Newsweek contributor and science editor ncreased scientific rigor in the
16 training of clinical psychologists (Baker, McFall, & Shoham, 2009; Mischel, 2009), Begley bemoaned what she perceived as a tenuous relationship between psychotherapy and scientific research, contrasting the specific ingredi ents approach (e.g., utilizing cognitive behavioral techniques for clients with panic disorders) with patently pseudo scientific modalities (e.g., facilitated communication or dolphin assisted therapy) Decades of research have clearly shown that far more people could benefit from psychotherapy than are availing themselves of it (Center for Mental Health Services, 2000; Gonzlez et al., 2010). Efforts to improve this situation, such as the new psychotherapy awareness initiative launched recently by the Amer ican Psychological Association (2012), represent an active focus of outreach in professional psychology. However, the question of how focusing on common factors or specific ingredients in these campaigns might affect attitudes toward seeking mental and beh avioral health care has yet to be investigated empirically. Moreover, the common factors approach, born of and supported by a vast body of empirical literature (see Wampold, 2009), has not been meaningfully included in the national conversation about the s cientific status of psychotherapy. By investigating reactions to the terminology and processes associated with two science based approaches that differ with regard to their emphasis on diagnosis and specific interventions, the findings of this study might suggest a viable pathway by which people who might benefit from therapy can be recruited to participate in it.
17 CHAPTER 2 STUDY 1 Overview In Study 1 I attempted to replicate the findings of previous investigations of psychotherapy preferences, which have revealed a clear preference for common therapy variables (such as a compassionate provider) relative to specific scientifically supported interventions ( Swan & Heesacker, 2013 ; Swift & Callahan, 2010). Study 1 also constituted a preliminary test of the med iational model of psychotherapy framing, perceptions of stigmatization, and help seeking attitude s (the specific ingredients stigma model) articulated in Chapter 1 Method Participants Recruitment for Study 1 TM (MTur k) service Registered MTurk TM users serve as an on demand and scalable workforce for simple computer based tasks that require human intelligence, such as categorizing digital photos or transcribing audio clips (Pontin, 2007). Recently, socia l scientists have begun to view MTurk TM as an untapped source of diverse research participants (Bohannon, 2011 ; Crump, McDonnell, & Gureckis, in press ). Studies have shown that MTurk TM users better represent the U.S. population than convenience samples of unde rgraduates (Paolacci, Chandler, & Ipeirotis, 2010) ; produce high quality survey data (e.g., adequate internal consistency and test retest reliability coefficients with evidence of criterion related validity ) even for remuneration as low as $0.02 (Buhrmeste r, Kwang, & Gosling, 201 1 ; Shapiro, Chandler, & Mueller, in press ); and report incidences of depression, general anxiety, and trauma exposure that m irror or
18 exceed the prevalence of these problems in the general population (Shapiro et al., in press). An a priori power analysis ( using G*Power 3.1.2 (Faul et al., 2009) found that 45 participants would be necessary to detect the medium sized effects reported in prior research using a similar method and procedure ( d = .50 ; Swan & Heesacker 2013 ). To achieve this minimum sample size, I invited 1 00 U.S. MTurk TM users to participate in this study in return for $0.50 1 each on July 29, 2012 Data collection occurred between 2:27 PM and 3:40 PM PDT. After the removal of two participants who failed a fidelity check to ensure that they actually attended to the survey questions (see below), 98 cases remained for analysis. Table 2 1 presents a Materials and Procedure A n online questionnaire ( hoste d by Qualtrics Survey Software; Appendix B contains ) introduced the study by providing a general description of psychotherapy ( the general process of addressing mental health concerns by talking with a psychologist or o ther mental health provider) a statement ( More than 20 years of scientific research have led to the conclusion that psychotherapy works quite well for those who use it ) and an introduction to the n otion that different therapists may hold divergent views on the question of how psychotherapy produces its benefits. Participants then viewed two separate answers to the question of how psychotherapy 1 Although evidence suggests that lower pay would not have adversely affected the quality of the data (Buhrmester et al., 2011), a higher financial incentive has been linked to both the speed of data collection a nd the rate of participant dropout (Crump et al., in press).
19 works, each purportedly written by a di fferent practicin g psychologist I constructed t hese descriptions by systematically distilling and adapting the four (common factors or medical model) components of each appr oach outlined by Wampold, Ahn, and Coleman (2001) and Wampold (2009). The first, reflecting a common factors approach, read : At their core, all psychotherapies provide a confiding relationship with a therapist, in which you can safely discuss your problems with someone who will work in your best i nterest. As that relationship develops, you'll both attempt to better understand the reasons for your troubles. The final step requires active involvement from both you and your therapist as you work to bring about a change in your life. The second, refl ecting a specific ingredients approa ch, read : Psychotherapy begins with the goal of an accurate diagnosis. This in turn points the way to an explanation for your symptoms, and the best course of treatment. Then, your therapist can administer a set of spec ific therapeutic interventions designed to target your particular problem. The benefits of psychotherapy are due to your participation in these scientifically established therapy ingredients. All participants received both descriptions, which were counte rbalanced randomly to prevent order effects. Several counseling psychology graduate students and PhD level psychologists provided feedback on accuracy, fairness, and affective valence. I chose a within subjects design under the assumptio n that simple descriptions of psychotherapy that differ in meta theoretical emphasis would standing psychotherapy schemas when presented in isolation ( see Shy & Waehler, 2008 for an example of the failure of simple t erminology changes to a ffect help seeking attitudes ). Instead, confronting participants with two contrasting descriptions will likely trigger the use of conscious, controlled decision making processes and override the activation of implicit stereotypes abo ut and attitudes toward therapy in general.
20 Following each description, participants rate d on a seven point Likert type scale (a) the likelihood that they would schedule an appointment with each therapist if they believed they were having a mental breakdo wn, and (b) whether they believed that psychotherapy of that sort would have value for a person like them. Adapted from Fischer and item, global Attitudes Toward Seeking Professional Psychological Help Short Form scale, these two criteri two established factors, Openness to Seeking Treatment for Emotional Problems, and Value and Need in Seeking Treatment (Elhai, Schweinle, & Anderson, 2008) respectively Strong inter item correlations supported the decisio n to combine these items into a single 77 ( r = .6 3 p < .001) for the common factors description and .8 0 ( r = .6 8 p description. Summing these two items produce d overall attitude s core s ranging between 2 and 14 for each psychotherapy description, with higher scores indicating more p ositive help seeking attitudes. Participants also complete d item Perceptions of Stigmatization by Others for Seekin g Help scale twice, once for each description. Vogel and colleagues (2009) found this scale, designed to measure the amount of stigmatization people believe they will experience from those in their social network for seeking psychological help to be a rel iable and valid measure of stigma perceptions across five collegiate samples. Summing the five Likert type items, which include d If the people in your life (friends, family, co workers) found out that you were enrolled in therapy l ike this description, to what degree do you d a total score for each
21 participant ranging between 5 and 20 with higher scores indicating more expected stigmatization for seeking help ( 1 or the common factors description and .93 for the specific ingredients description ) A s ingle fidelity check item assess ed whether participants read and could recall the two psychotherapy descriptions ( Which of the following was not part of a psy chologist's answer on the previous page? ; the foil us ed to exclude participants read cognitive behavioral therapy works best for treating depression and anxiety disorders, but not for eating disorders ). Two participants chose the foil, and were thus remov ed from the data set. The final page of the survey contained demographic items (Table 2 1) Results All continuous variables appeared suitable for parametric analy ses (i.e., absolute skewness and kurtosis coefficients less than 1.0) Unless otherwise noted all analysis assumptions were met. When comparing multiple means as part of a single analysis, I adjusted the alpha level using Bonferroni correction to control for family wise All participants in the final sample ( N = 98) answere d all help seeking and stigma perception questions, and only one participant failed to answer one demographic item. Help Seeking A repeated measures multivariate analysis of variance revealed a significant multivariate effect of meta model framing on help seeking attitudes and perceptions of stigma tization = .84, F (2, 96) = 9.42, p < .001, f = .44. Consistent with H ypothesis 1 simple effects decomposition within each repeated measure revealed that participants reported significantly more positive attitudes toward the common factors description ( M = 9.91, SD = 2.68) than the specific ingredients description ( M = 8.73, SD
22 = 2.76) p = .001, d = 35 2 Of 98 final cases, 5 0 0 % preferred the common factors description, 24 5 % preferred the specific ingredients description, and 25 5 % preferred neither. Stigma Con sistent with H ypothesis 2 participants indicated expecting significantly less stigmatization by others for seeking therapy in the common factors condition ( M = 8.56, SD = 3.71) than in the specific ingredients condition ( M = 9.60, SD = 4.21), p < .001, d = 38 To test H ypothesis 3 ( differences in perceptions of stigmatization for seeking each type of therapy will mediate the relationship between psychotherapy framing and help seeking attitudes ) I first calculated a preference score for each participant b y subtracting their attitude score toward the specific ingredients description from their attitude score toward the common factors description ( M = 1.17, SD = 3.34; a score of 0 indicates no preference, positive values indicate a common factors preference, and negative values indicate a specific ingredients preference). S econd, I computed a perceived stigma main effect stigmatization scores across both conditions ( M = 31.83, SD = 7.43). Entering this variable into the regression model allowed the overall effect of perceived stigma to be controlled, and prov ided a test of moderation (see Judd, Kenny, & McClelland, 2001 for an overview of this repeated measures approach to mediation tests ). Third, I calculated a stigma perception difference score for each participant by subtracting their stigma score toward the common factors description from their stigma score toward the specific 2 I d in repeated measures designs throughout this dissertation dividing mean difference s by average standard deviation s and correct ing for the correlation s between dependent observations.
23 ingredients description ( M = 1.04, SD = 2.79) Finally, I regressed the difference i n seeking attitudes onto both the stigma main effect (sum) and the stigma difference score The overall model was significant, F (2, 95) = 6.78, p < .01, R 2 = p = .95), indicating that perceived stigma did not moderate the effect of psychotherapy framing on help seeking attitudes. However, consistent with H ypothesis 3 the difference in ed differences in help seeking attitudes p < .001), indicating that perceptions of stigmatization by others did mediate the effect of psychotherapy framing on help seeking attitudes. A statisticall y significant model intercept ( B = 1.17, p < .001) qualified this as a partial mediation. Discussion Prior research has documented a clear preference among both active therapy clients (Swift & Callahan, 2010) and the general population ( Swan & Heesacker, 2 013 ) for psychotherapy guided by common factors successful replication of the latter finding is im portant for two reasons. First, reproducibility, especially in the case of novel or preliminary results is crucial for the estimati on true effect sizes ( see the Open Science Collaboration, 2012 ). Discovering the same trend in multiple independent samples also reduces the likelihood of accepting spurious results and conclusions Second, Study 1 addressed a methodological limitation of my prior work Previously ( Swan & Heesacker, 2013 ), my coauthor and I wrote and presented study participants with two descriptions of psychotherapy one emphasizing common factors and one emphasizing specific evidence based therapy ingr edients which ostensibly represented straightforward, non technical distillations of each position (see footnotes one and two in Chapter 1 for the full text of these descriptions ) Our aim was principally
24 to represent the essence of each model with the sort of simple verbiage a n advocate mig ht use to explain the process of psychotherapy to a novice. However, both characterizations le ft much room for disagreement from proponents of both models, and a gap between what has been described in the scholarly literature and what participants reacted to in the study. The present study bridged this gap, summarizing more faithfully and thoroughly each position as described by psychotherapy scholars (namely, Wampold, Ahn, & Coleman, 2001; and Wampold 2009 ) u sing similar phrasing (e.g., con fiding relationship with a therapist ; the benefits of psychotherapy are due to your participation in these scientifically established therapy ingredients ) and orderi ng of various components 3 Thus rather than relying on my own interpretations of each posi tion this study attempted to transport representative samples of the largely internal professional discourse on these two meta theoretical positions into to the public, non professional arena Although the effect sizes obtained in th e present study were s omewhat smaller than those obtained using the previous descriptions (e.g., d = .3 5 in this investigation versus d = .50 in Swan & Heescaker, in press ), the overall result of a preference for the common factors approach was fully reproduced This conceptual replication rules out the possibility that our previous results were due solely to word choice Study 1 therefore provided further scientific support for the claim that promoting psychotherapy by underscoring its nonspecific ( or, humanistic ; McKay et al., 2007) 3 ogical explanation for the disorder, problem, or complaint; (c) theoretical conceptualization and knowledge are sufficient to posit a psychological mechanism of change; (d) the therapist administers a set of therapeutic ingredients that are logically deriv ed from the psychological explanation and the mechanism of change;
25 features rather than a model of diagnosis and treatment will increase the likelihood of people seeking help when in need T h e finding that others partially mediated this common factors pref erence reinforces this conclusion. T he stigma associated with mental illness and psychological counseling is the most frequently cited reason for the decision to avoid seeking help (Corrigan, 2004) and r ecent r esearch suggest s that mental illness stigma r emains a significant problem in the United States (e.g., Pescosolido 2013; Pescosolido et al., 2010; Schwenk, Davis, & Wimsatt, 2010 ) Chapter 1 of this dissertation introduced a theoretical ly grounded model to joi n these findings and the stigma literatur e with the common factors preference effect po siting that an awareness of mental illness stigma would lead individuals to feel less inclined to seek help from a provider who they believe will conceptualize their distress as an illness Although caution is warranted when using mediational analyses to infer causality ( Bullock, Green, & Ha, 201 0 ), the results of Study 1 pro vide preliminary support for the specific ingredients stigma model. The y also raise several important questions about the conditions under which the preference for psychotherapy framed by common factors will arise. in addition to attempting to replicate the findings of Study 1, sought answers to two of these questions.
26 Table 2 1. Study 1 s ample c haracteristics ( N = 98) Measure % n Measure % n Age Ethnic i dentification 18 24 28.1 27 Hispanic 7.1 7 25 34 38.5 37 Household income 35 44 17.7 17 Less than $9,999 9.2 9 45 54 7.3 7 $10,000 $19,999 8.2 8 55 64 8.3 8 $20,000 $34,999 26.5 26 65 + 0.0 0 $35,000 $49,999 21.4 21 Gender $50,000 $99,999 27.6 27 Female 46.4 45 $100,000 $149,999 6.1 6 Male 53.6 52 $150,000+ 1. 0 1 Education Region 9th to 12th grade 1. 0 0 Northeast 26.5 26 High school graduate 9.2 9 Midwest 21.4 21 Some college 29.6 29 South 22.4 22 Associate degree 11.2 11 West 29.6 29 College graduate 34. 7 34 Marital s tatus Postgraduate work/degree 14. 3 14 Married 28.6 28 Racial i dentification a Never married 50.0 49 Asian 15.3 15 Living with partner 14.3 14 Black/African American 11.2 11 Divorced/ s eparated 5.1 5 Native American/Alaska Widowed 2.0 2 Native 1.0 1 Previous t herapy Native Hawaiian/Pacific Yes ( p a st or p resent) 43.9 43 Islander 1.0 1 Common f actors 31.6 31 White 75.5 74 Specific i ngredients 13.3 13 Other 1.0 1 Neither 6.1 6 a Participants were allowed to choose more than one racial identification category. Note. Due to missin g data on demographic items, some totals fail to reach 100% of the final sample size ( N = 98).
27 CHAPTER 3 STUDY 2 Overview Study 1 amassed strong support for the specific ingredient s stigma model However, it did so with a relatively small sample of partic ipants ( N = 98) drawn from the s ame volunteer pool (MTurk TM users) that I utilized in prior investigations of similar research questions Study 2 re tested hypotheses 1 3 in an independent sample of participants from a new source (SocialSci.com) with the aim of increasing confidence in the external validity of results It also pursued this exploratory (third) research aim to investigate two likely moderators of psychotherapy preferences. Personal Preference versus Recom mendations for Others The first of these likely moderators concerned a possible discrepancy between the type of psychotherapy one would and the type one would recommend to another person. S tudies have shown that people often internalize the public stigmatization of mental illness and treatment (Link & Phelan, 2001). Vogel and colleagues (2007) placed this notion of internalization at the center of a causal chain, having found in a large ( N = 680) co llege student sample that the relations hip between perceiving public stigma (a perception held by members of a society that an individual is socially unacceptable) and willingness to seek counseling was mediated fully by self stigma (a perception held by the individual that he or she is sociall y unacceptable) and general attitudes toward obtaining professional psychological help ( ) If concerns about stigmatization account for (part of) the public preference for common factors, as my specific ingredients stigma model suggests, thin king about
28 recommending help for someone else should attenuate the common factors preference effect. That is, imagining the public stigmatization of others may bypass the activation of internalized self stigma and its negative impact on self esteem, dimini sh the effect of perceived stigmatization in general and increa se the attractiveness of the specific ingredients model. A nother source of i ndirect s upport for this self other discrepancy prediction may be found in the social psychological study of behavio r attribution Decades of empirical investigation have shown that when asked to infer the cause of people very often rely on highly predictable reasoning heuristics Among the most well documented of these is the correspondence bias (Jones, 1979 ) which describes the tendency for people to over at the expense of equally likely external, situational explanations The actor observer effect (Jones & Nisbett, 1987) adds to th is phenomenon the converse when making attributions for their own behavior, people tend to overestimate situational factors and downplay the influence of stable traits and p roclivities. Perhaps the most familiar illustration of the se errors in action is th e case of a law breaking automobile driver. After observing another driver fail to observe a stop sign (or commit some other traffic infraction or discourtesy) people tend more often personality factors so inconsiderate the happenstance of she must have been temporarily distracted previously offended driver later becomes an offender breezing through a stop sign
29 himself his attribution is li kely to invert attributions for mental distress are immune to these same reasoning biases 1 Consider the same automobile driver, now struggling with a bout of major depression To explain the etiology of his ow n depressive symptoms, he might conjecture that he has been under a great deal of stress (situational attribution), and there by think relatively favorably of psychotherapy framed by the image of someone listen ing compassionately and help ing him to bring ab out situational life c hanges (the common factors model ) on the other hand he may infer that something has gone seriously wrong psyche (internal attribution), and that his neighbor wo uld therefore benefit most from a clearly defined and empirically validated intervention (the specific ingredients model) Although neither of the se two approaches to psychotherapy advocate explicitly for a particular cause of mental distress, the specific seem to imply an internal cause; a disorder within a person that can be ameliorated with the application of the correct treatment (Wampold, 2009), perhaps making it seem more appropriate for other people with psychologic al problems This is not to suggest that such lay conceptions that the common factors model encourages external attributions while the specific ingredients model encourages internal ones are correct. Indeed, a specific psychotherapeutic ingredient may be designed to teach a client new behaviors that will extinguish previously learned 1 I discovered no research testing this hypothesis directly. However, a robust liter ature does exist on the and discrimination toward the mentally ill (see Corrigan et al., 2003 for an overview of the attribution model of pu blic discrimination toward persons with mental illness). The question of whether attributing decreases stigma has yet to be resolved empirically (see Phelan
30 (external) environmental contingencies such as the association of snakes with fear However, applying and extending the principals of attribution theories to attitud es toward these two approaches to psychotherapy suggests a possible perceptual discrepancy worthy of exploration. Different Types of Mental Distress The second likely moderator of interest in Study 2 concerns the type of psychological problem that participants anticipate experiencing. The measure recommended and used most frequently in the psychological literature (and indeed the measure used in this dissertation) to assess attitudes toward seeking p rofessional psy chological help Fischer and Attitudes Toward Seeking Professional Psychological Help Short Form scale ignores this potentially rich source of situational variance. For instance, does t hinking about persistent feelings of sadness trigger the s ame set of set of attitudes toward seeking help as thinking about a struggle with opiate addiction binge eating, or auditory hallucinations ? connote different problems for different people, obscuring the differential impact they may have on help seeking attitudes. After first having participants consider psychological distress in the abstract Study 2 ask ed them to also indicate their therapy preference (common factors, specific ingr edients, no preference, or neither) for several different problems for which people often seek help from a psychologist. Method Participants SocialSci (SocialSci .com ), a web based survey hosting and participant pool service designed specifically for academ ic research ( SocialSci, 2013 ), provided a
31 sample of participants for Study 2. TM Service, SocialSci offers small monetary rewards ( e.g., points redeemable for Amazon.com gift cards) to anyone 2 who signs up for a free user account and elect s to complete online surveys SocialSci offers an ad ditional layer of quality assurance beyond those offered by MTurk TM however, by checking for anomalies in response patter ns 3 A lthough a n a priori power analysis ( revealed that only 90 participants would be necessary to detect the smallest of the two effect sizes obtained in Study 1 ( d = 35 ) any post hoc between participant exploration s of subgroups (e.g., those who have never participated in psychotherapy) would require substantially more power to guarantee a large enough sample size in each cell I therefore invited a total of 400 SocialSci users to participate in Study 2 After removing 25 who failed a fidelity check to ensure that they act ually attended to the survey questions (see the Materials and Procedure section below) 375 cases remained for analysis. Table 3 1 presents a Materials and Procedure Study 2 replicated exactly the mat erials and procedure of Study 1 participants received identical instructions, the same psychotherapy descriptions, and the same items to assess help seeking attitudes perceptions of stigm atization by others, and task attention (fidelity check). My two ite m measure of help seeking attitudes again 2 SocialSci recruits participants though a distributed ad vertising network of more than 40 web sites such as Facebook .com, as well as a variety of print media. P articipants may also refer one another d irectly (SocialSci, 2013). 3 See https://research.socialsci.com/docs/contents/144 vetting for more information about this vetting system.
32 produced acceptable C coefficients [ 81 ( r = .6 9 p < .001) and .76 ( r = .6 1 p < .001) for the common factors and specific ingredients description s, respectively] item Perceptions of Stigmatization by Others for Seeking Help scale similarly proved internally consistent in both conditions (C 92 and 93, respectively) Before p resenting demographic questions Study 2 included one additional page of questions to address the two exploratory aims outlined previously in this chapter (Appendix C contains the full text of this additional page). First, participants were re presented with both (counterbalanced) psychotherapy descriptions and asked to again indicate their help seeking attitudes toward each This time, however, I instructe d them other people in psychotherapy, rather than two help s w ere also modified slightly to reflect th e shift in perspective 4 A total of four help seeking attitude scores could therefore be calculated for each participant in Study 2 all using the same metric: one pair for their own attitudes toward seeking help from the two type s of therapy and a second comparable pair for their attitudes toward others seeking help s showed somewhat weaker internal reliability than their unmodified (help seeking for self) counterparts : C = 62 ( r = 45 p < .0 1) for the common factors description and 67 ( r = 51 p < .0 1) for the specific ingredients description All analyses reported in the following sections of this chapter that included the help seeking for others variable 4 How likely is it that you would schedule an appointment with this therapist if you believed you were having a Other people should schedule an appointment with this therapist if they believed they were having a mental breakdown Psychotherapy of this kind would not ha Psychotherapy of this kind woul d not have value for other people (emphases in original; the second item in each set was reverse coded).
33 therefore also subsequently examined each help seeking for others item separately to search for discrepancies. Next, u sing descriptions of five major categories of mental disorder ( depression, anxiety, eating disorders substance abuse and thought disturbances) ada pted from seekers 5 additional survey page also asked participants to indicate which of the two descriptions of therapy (common fac tors, specific ingredients, no preference, or neither) they w ould prefer if they experienced symptoms of each problem Finally, Study 2 added two additional questions meant to measure potential confounds in the research design : Which of these two approaches to therapy do you think that they author of this survey fav ors? ; and, Before you started this survey, which of these two types of therapy would you have expected to receive if you sought help from a psychologist ? The former serve d as a manipulation check to ensure bias free wording, while the latter served as a me ans of testing the assumption that preferences are not merely a result of pre existing expectations about what occurs in therapy. Results All continuous variables appeared suitable for parametric analy ses (i.e., absolute skewness coefficients less than 1. 5 6 ). Unless otherwise noted, all analysis sp assumptions were met. When comparing multiple means as part of a single analysis, I 5 http://www.ncbi.nlm.nih.gov/pubmedhealth/ 6 The distribution of scores for the Perceptions of Stigmatization by Others for Seeking Help scale appear ed somewhat negatively skewed (statistic = 1.42) and leptokurtic (statistic = 2.37) for the common factors description. Both coefficients seemed to reflect a large number of participants who perceived no stigmatization at all for this type of therapy ( n = 144; approximately 30% of the overall sample). This was slightly less pronounced for the specific ingredients description ( n = 92, approximately 25% of the overall sample; kurtosis statistic = 1.46). The general linear model equations I chose to analyze St are likely sufficiently robust to handle these small deviations of normality without any adverse effects.
34 adjusted the alpha level using Bonferroni correction to control for family wise error All participants in the final sample ( N = 375 ) answered all survey ite ms. Replicating Study 1 A repeated measures multivariate analysis of variance revealed a significant multivariate effect of meta model framing on help seeking attitudes and perceptions of stigma tization = .8 7 F (2, 373 ) = 28.52 p < .001, f = 39 Consistent with Study 1 ( H ypothesis 1 ) simple effects decomposition of each within participant outcome revealed that participants reported significantly more positive attitudes toward the common factors description ( M = 10.31 SD = 2. 75 ) than the specif ic ingredients description ( M = 9.48 SD = 2.7 9 ) p = .001, d = 29. Of 375 final cases, 45 9 % preferred the common factors description, 23 2 % preferred the specific ingredients description, and 30 9 % preferred neither. Again consistent with Study 1 ( H ypo thesis 2 ) participants indicated expecting significantly less stigmatization by others in the common factors condition ( M = 8. 44 SD = 3.7 9 ) than in the specific ingredients condition ( M = 9. 11 SD = 4. 09 ), p < .001, d = 3 3 R egressing the difference in seeking attitudes onto both the stigma main effect (sum) and the stigma difference score revealed a significant omnibus effect R 2 = 08, F (2, 372 ) = 15.57 p < .0 0 1. Inconsistent with Study 1, the main effect of stigma was a weak but si 14 p < 01 ), indic ating that perceived stigma moderate d the effect of psychotherapy framing on help seeking attitudes. As perceived stigma for seeking help in general increased, the likelihood of a preference for common factors i ncreased in concert. T also significantly predict ed differences in help 27 p < .001), indicating that perceptions of stigmatization by others mediate d the effect of
35 psychotherapy framing on help seeking attitudes as well supporting H ypothesis 3 and the specific ingredients stigma model. A statistically significant model intercept ( B = 1.1 5 p < .001) again qualified this as a partial mediation. Exploratory Analys es Personal p reference ver sus recommendations for o thers attitudes toward seeking help from the two types of therapy to their relative attitudes toward others seeking help I conducted a second RMANO VA with two within participant factors: psychotherapy fram ing (common factors versus specific ingredients) and help seeking target (self versus other). A significant interaction term [ = 95 F ( 1 37 4 ) = 18.55 p < .001, f = 22 ] suggested that the effect of psychotherapy framing did indeed depend on the target (self or other ) Simple effects decomposition revealed toward seeking psychological help were significantly more favorable for other people than for themselves for both types of therapy ( p 001; d common factors and specific ingredients descriptions, respectively) Second, when considering others seeking help, participa nts on average expressed no preference between common factors ( M = 11.16, SD = 2.14) and specific ing redients ( M = 1 0 94 SD = 2.22 ), p = .09, d = .09. Figure 3 1 depicts th ese interaction effect s graphically. Given the marginally combining the help seeking for others items, I subsequently re ran the RM ANOVA twice, each time entering one of the two individual help seeking for others items instead of composite scores. No meaningful differences emerged
36 Different types of mental distress Figure 3 2 shows the percentages of participants who indicated that t hey would prefer psychotherapy framed by common factors, psychotherapy framed by specific ingredients, had no preference between the two, and preferred neither when considering seeking help for five different types of psychological distress (depression, an xiety, eating disorders substance abuse and thought disturbances). A series of continuity corrected McNemar tests revealed significant differences between the number of participants who preferred common factors and the number that preferred specific ingredients for depression [ = 64.70, p < 001], eating disorders [ = 35.46, p < 001] substance abuse [ = 30.88, p < 001], and thought disturbances [ = 57.67, p < 001], but not for anxiety [ = .38, p = 540] Combined with Figure 3 2, these results paint a clear picture: participants expressed a strong preference for common factors when the psychological p roblem involved depressive symptoms, but an equally strong preference for specific ingredients when they imagined experiencing symptoms of an eating disorder, substance abuse or psychotic disturbance A roughly equal number of participants preferred each when imagining symptoms of anxiety. Previous p sychotherapy e xposure my prior work ( Swan & Heesacker, 2013 ) using independent samples and variation in research methods. Both o f the prese nt studies indeed found an overal l preference for therapy framed by common factors However, to support fully the claim that campaigns to increase the utilization of mental health services should stress the importance and presence of nonspecific common factors, rather than the scientific credibility of individual interventions or techniques, these data must show that even those who have
37 never experienced psychotherapy the group arguably most in need of such targeted advertising prefer the common factors approach. Indeed, w hen I added exposure to therapy (past or present versus no exposure) as a between subjects factor to a new RMANOVA with psychotherapy framing as the within participant factor and help seeking attitudes as the criterion s imple ef fects decomposition showed that even non clients exhibited a preference for common factors guided therapy ( M = 9.59 SD = 2.72 n = 17 3 ) relative to the specific ingredients approach ( M = 8.79 SD = 2.78 n = 173 ), p < .001, d = 31 Expectations The spec ific ingredients stigma model rel ies preferences for therapy framed by common factors are not simply a result of pre existing expectations about what occurs in therapy Although psychotherapy preferences and expectations are lik ely to covary greatly their c orrelation should not be perfect (e.g., Tracey & Dundon, 1998) A cross tabulation of categorical psychotherapy preferences [common factors ( n = 172), specific ingredients ( n = 87), or neither ( n = 116)] 7 and expectations [com mon factors ( n = 239), specific ingredients ( n = 108), or neither ( n = 28) ] strong but imperfect covariation [ (4, N = 375 ) = 22.88, p < 001 c = .18 ]. For instance, of 173 participants who preferred common factors, 29 expec ted to receive therapy consistent with the specific ingredients description, and 14 expected neither. That is, approximately 25% of those who preferred common factors did not expect to encounter it prior to beginning th is study 7 calculated by subtracting attitude sco res toward the specific ingredients description from attitude scores toward the common factors description ( M = .83, SD = 2.85). A score of 0 indicates no preference, positive values indicate a common factors preference, and negative values indicate a spe cific ingredients preference.
38 Demand characteristics Dem and characteristics often pose threats to the internal validity of studies in which par ticipants are asked to disclose their attitudes In these studies participants might have deduced a particular allegiance to one of the two approaches to therapy on the part of the author, and thus responded in a socially desirable manner wanted them to respond ) Indeed, many m ore participants surmised that my allegiance lay with the common factors approach ( n = 117 ) than the specific ingredients approach ( n = 81 ). However, most participants detected no author preference ( n = 177), and a cross tabulation of psychotherapy prefere nces and beliefs about allegiance showed only a small and statistically insignificant relationship [ (4, N = 375 ) = 7.09 p = .13 c = .1 0 ]. The same was true when examining only those who did suspect an author allegiance ( i.e., correcting for the the influence of the large number of participants who did not on the chi square statistic): (2, N = 198 ) = 4.97, p = .08, c = .16. Discussion Study 2 replicated two important Study 1 effects First, it confirmed that even those who have never experienced psychotherapy report more positive attitudes toward seeking help when therapy is guided by common factors. Second, it reproduced in an independent sample the mediating effect of perceived stigmatization on the relationship between psychotherapy framing (common factors versus specific ingredients) on help seeking attitudes. Although the omnibus effect of perceived stigmatization for seeking mental health services emerged as a significant moderator of therapy preferences in Study 2 (but not in Stu In any case, common
39 factors prevailed on both counts: those who perceived more stigmatization for seeking help in general were more likely to prefer the common factor s framing, and, independently, those who perceiv ed relatively more stigmatization for seeking the specific ingredients therapy preferred common factors. A purposive test of m oderated mediation may help to elucidate this discrepancy in future research. Neither demand characteristics nor prior expectation s about psychotherapy could explain the common factors preference effect Given evidence that the influence of stigmatization on help seeking attitudes may require internalization, and given several well documented findings from the psychological science o f behavior a ttribution (i.e., the tendency for people to attribute their disposition), my specific ingredients stigma model can accommodate the self other discrepancy findi ngs of Study 2. An absen ce of stigma internalization may account for the finding that help seeking attitudes for others were significantly more positive for others than for participants themselves imagining the negative impact of stigmatization on others may not trigger the same negative associations (e.g., fears of social devaluation), therefore attenuating any preference participants held between the two. This represents only one possible interpretation of the self other discrepancy, however. Future research should test these at tribution hypotheses directly. It is important to note that the common factors preference effect did not reverse entirely when participants considered seeking help for others which may have indicated a severe case of the actor observer bias. I nstead the two approaches were rendered equally attractive (for others). More acceptable therapy options mean a greater likelihood of finding a provider and of recovery or improvement.
40 More research is needed to elucidate the preference trends related to psychotherap y framing and seeking help for different disorders. The emergent picture which suggests that people may prefer common factors when imagining depressive symptoms but hold an equally strong preference for specifi c ingredients when they imagine experiencing s ymptoms of an eating disorder, substance abuse, or psychotic disturbance should be interpreted with caution, and multiple explanations should be explored. substance abuse, and though t disorders (i.e., the actual verbiage to which participants reacted in this study ) imply uncontrollab le, internal etiologies ; Appendix C ). Lay theories about the etiology of each of these disorders likel y influenced these preferences, and those lay theories likely differ between people. Nevertheless, these data suggest strongly that the help seeking literature should attend to the variation in attitudes toward different disorders, rather than asking peopl e to consider mental distress in aggregate without a theoretical rationale for doing so. Although the effect sizes obtained in Study 1 and Study 2 ranged between small recognized standards, the potential human impact of psychotherapy framing on help seeking may be substantial. The evidence is clear that far fewer people seek professional psychological help than would benefit from it. A one point increase on a 14 point scale could translate into hundreds or thousands more people receiving care, and improve, even if only slightly, the state of mental health in the United States. In Chapter 4 I attempt to place all of the aforementioned findings
41 into historical and contemporary contexts, and discuss recommendations for psych otherapy research and practice.
42 Table 3 1. Study 2 s ample c haracteristics ( N = 375) Measure % n Measure % n Age Ethnic i dentification 18 24 41.9 157 Hispanic 5.9 22 25 34 34.9 131 Household income 35 44 10.7 40 Less than $9,999 12.8 48 45 54 8.3 31 $10,000 $19,999 11.2 42 55 64 2.4 9 $20,000 $34,999 17.3 65 65 74 1.6 6 $35,000 $49,999 16.0 60 Gender $50,000 $99,999 26.1 98 Female 58.1 218 $100,000 $149,999 10.4 39 Male 41.9 157 $150,000+ 6.1 23 Education Region 9th to 12th grade 0.5 2 Northeast 32.3 121 High school graduate 4.3 16 Midwest 24.8 93 Some college 28.5 107 South 19.7 74 Associate degree 4.8 18 West 23.2 87 College graduate 33.9 127 Marital s tatus Postgraduate work /degree 28.0 105 Married 27.2 102 Racial i dentification a Never married 50.7 190 Asian 9.0 34 Living with partner 18.1 68 Black/African American 2.1 8 Divorced/ s eparated 3.7 14 Native American/Alaska Widowed 0.3 1 Native 1.3 5 Previous t herapy Native Hawaiian/Pacific Yes ( p ast or p resent) 53.9 202 Islander 0.0 0 Common f actors 44.3 166 White 85.6 321 Specific i ngredients 14.9 56 Other 2.1 8 Neither 4.3 16 a Participants were allowed to choose more than one racial identification category. Six participants identified solely without selecting any of the options listed above. Note. Due to missing data on demographic items, some totals fail to reach 100% of the final sample size ( N = 375).
43 Figure 3 1 N = 375) attitudes toward seeking two varieties of psychotherapy one framed by common factors and framed one by specific ingredients for themselves or for others. Scores ranged between 2 and 14, with higher scores indicating more positive help seeking attitudes. Error bars rep resent 95% confidence interval s
44 Figure 3 2 Percentage of participants ( N = 375) who indicated that they would prefer psychotherapy framed by common factors, psychotherapy framed by spec ific ingredients, had no preference between the two, and preferred neither when considering seeking help for five different types of psychological distress.
45 CHAPTER 4 GENERAL DISCUSSION A New Perspective dates back at least to 1952, when the eminent psychologist Hans Eysenck published a nearly fatal indictment against his own burgeoning field of clinical psychology. Undoubtedly influenced by the contr olled clinical trials ( Kaptch u k, 1998 ), Eysenck expressed in his now classic article great concern over the paucity of scientifically rigorous psychotherapy outcome evaluations. At the time, the best available evidence consisted of less than two dozen unco ntrolled studies of discontent arose from his belief that the psychodynamic therapies of the 1950s were demonstrably inferior to therapies which focused exclusively on overt behavior (e.g., Eysenck, 1961 choanalytic, humanistic, interpersonal, experiential, cognitive behavioral) proffered and defended competing explanations of and treatments for mental disorder (Wampold, 2009). More than 60 years later, the question of overall efficacy has been unambiguou sly resolved: hundreds of studies and scores of meta analyses have shown that psychotherapy is in fact extraordinarily effective, yielding an average standardized effect size estimate of.80 ( e.g., Smith & Glass, 1977 ; see Wampold, 2001 for a review). Theor etical divides persist between schools of thought (e.g., between intrapsychic and behavioral explanations for psychological distress), but several decades of efficacy and
46 p roduces better outcomes than its other mainstream (i.e., well studied) competitors (e.g., Ahn & Wampold, 2001; Cuijpers et al., 2008; Ehlers et al., 2010; Robinson, Berman, & Neimeyer, 1990; Shapiro & Shapiro, 1982; Wampold, 2001; 2009; Wampold et al., 200 2 ) Recent years have therefore seen the brand wars evolve into a more general debate about whether any theoretically derived techniques contribute uniquely technique; Munder et al., 2012) to positive therapy outcomes. Approaches to psychotherapy built upon the empirical finding that nonspecific common factors account for the majority of variance in successful therapy outcomes across different types of therapy (see, for to serve as science based alternatives to models which maintained the superiority of specific ingredients (e.g., exposure therapy for post traumatic stress disorder). As I noted in the opening pages of this dissertation, proponents of both positions can point to much research in support of their claims ( Lilienfeld & Arkowitz, 2012). t the often polemical professional discourse concerning the contributions of common factors and specific ingredients to constituency: its consumers. Psychotherapy scholars have acknowledged the 2006) and scientific (e.g., Swift et al., 2011) grounds. The data I have presented here show clearly that preferences matter even before clients sc hedule their first
47 appointment framing the psychotherapeutic process with either common factors or help when in need. Given the large numbers of people who would li kely benefit from therapy but fail to present for services, the finding (now obtained across four independent samples in total ) that a majority of the public would prefer the common factors approach suggests a relatively simple tactic for increasing servic e use: when describing psychotherapy to non professionals, practitioners of all theoretical persuasions should emphasize common factors, rather than their ability to diagnose and treat. The exploratory analyses presented in Chapter 3 also indicate that the opposite emphasis (specific ingredients over or in addition to common factors) will be most likely to encourage help seeking when discussing eating disorders, substance abuse, or thought disturbances. Nevertheless, in general, when thinking about themselv safe atmosphere (a healing context) in which they can safely explore their troubles. The specific ingredients stigma model represents a viable explanation for this effect. According to this framework, which itself derives from the modified labeling theory of mental illness stigmatization, the common factors framing owes part of its relative attractiveness to its focus on situational attributions for psychologic al problems. esteem. The necessity of employing diagnostic labels in specific in gredients approaches 1 carries many important benefits, including the ability for clinicians to 1 After all, how can one apply the correct psychological procedure or intervention if one does not have a
48 communicate efficiently and the ability to operationalize critical research variables (e.g., measuring changes in a standard set of depressive symptoms; Lilienfe ld et al., 2009). There is even evidence to suggest that diagnostic labels can increase the positivity of with attention deficit/hyperactivity disorders; Cornez Ruiz & H endricks, 1993). The notion that the expectation of a mental health diagnosis may impede help seeking behavior, however, had not been previously investigated. Although this dissertation is certainly not the first attempt to show a relationship between clin ical diagnosis and mental illness stigma (e.g., Rosenhan, 1973; Corrignan, 2007), the specific ingredients stigma model articulated here offers a new perspective on the costs such an approach may carry. Limitations and Future Directions These interpretatio ns must be qualified by several limitations, which in turn suggest directions for future scholarship. Foremost, although more demographically Mechanical Turk TM service in pool do not perfectly represent the general population of U.S. adults. For instance, both of my samples underrepresented participants who identify as Hispanic. It is also worth noting in this cialSci) effect sizes were somewhat smaller than their Study 1 (MTurk TM ) counterparts (e.g., .29 versus .35 for help seeking; .33 versus .38 for perceived stigmatization; and .27 versus .36 for the indirect effect of stigma on help seeking). Each of these re Statistical Manual of Mental Disorders serves as the taxonomic system for the vast majority of specific ingredients approaches to psychotherapy.
49 However, they might also reflect slight differences in sample characteristics. Unlike TM service, SocialSci has not yet received widespread attention or endorsement from socia l scientists, and little is known about either the representativeness of its participants or the quality of the data they produce. In the present studies, SocialSci participants were somewhat more educated (e.g., 14.3% of participants in Study 1 held a pos tgraduate degree, compared to 28.0% in Study 2), slightly less diverse in their racial identifications (75.5% identified as White in Study 1, compared to 85.6% in Study 2) and had more personal experiences with psychotherapy (43.9% reported current or prev ious psychotherapy in Study 1, compared to 53.9% in Study 2). Whether these differences represent sampling error or systematic patterns in the respective demographics of each participant pool remains an open question. Future research should strive for the most nationally representative sample possible to bolster confidence in the generalizability and external validity of these results. A second important limitation concerns the wording of my specific ingredients and common factors descriptions. I did not c onstruct these very brief representations to capture completely the breadth, depth, and heterogeneity within each meta theoretical model Certainly, proponents of both approaches might disagree with aspects of these characterizations. For instance, I do no t mean to imply that proponents of the medical model ignore nonspecific therapy factors. Indeed, there is no reason to suspect that clinicians who focus on matching symptoms to empirically supported interventions are less attentive to these elements, such as a strong therapeutic relationship, than advocates of common factors theory. Most of the theoretical work on the demarcation between the two meta models, including the works I used to distill the descriptions used
50 in these studies, comes from Bruce Wampo ld, an outspoken advocate of common this lacuna is that advocates of specific ingr edients approaches do not recognize the common factors model as scientific (Wampold, 2013). Moreover, clients may not face a dichotomous choice between therapies guided by specific or nonspecific factors in everyday life. I aimed only to test the notion th at the relative emphases placed on each meta theory when describing the gist of treatment matters. Insofar as they emphasize differences rather than similarities, I view this study as a preliminary step toward ition. Future studies should vary the wordings, isolate specific features, and include descriptions of therapy utilizing a combination of the two models. Finally, I advise caution when interpreting the results of this study of help seeking attitudes as a gauge of what people will actually do when they experience a need for professional psychological help. Although attitudes often predict behavior (and there is evidence that this is true for help seeking attitudes; Ten Have et al., 2010), there are also lik ely to be conditions under which they do not (see Fazio, 1990 for a model). Moreover, this study focused exclusively on help seeking attitudes, ignoring other potentially important factors such as treatment success or attendance patterns, which may be dive rgently affected (or altogether unaffected) by meta model framing. For instance, Garland et al. (2012) found that among children with disruptive behavior problems in a community based clinic, the intensity of evidence based intervention delivery (the time spent on the practice element and the thoroughness with which it was
51 administered ) was marginally ( p = .059) related uniquely to the total number of treatment sessions children and their caregivers attended during the 16 month study period. Examining prefe rences among children and their caregivers may be especially important, especially given the evidence presented here concerning the discrepancy between what people prefer for themselves and for others (e.g., their children). C onclusion The goals of psychol promoting rigorous, objective, and empirically based psychological treatments; e.g., Baker et al., 2009 ) are more than laudable status of a scientific di scipline, clinical and counseling psychologists must continue to search for the most effective methods of helping those in emotional or psychological distress to improve the quality of their lives. They must do this as scientists, employing the most recent advances in research design and statistical analysis to sort the wheat from the chaff; to identify treatments that work, treatments appear to work but wither under the lights of controlled observation, and treatments that do measurable harm (Lilienfeld, 2 007). But they must also accept a paradigm shift when the data suggest the time has come: t has now retuned enough disappointing data to warrant its sunset. The common factors approac h to psychotherapy rep resents a remarkably viable science based approach to providing help to those suffering or hoping to make life changes for the better. Unfortunately, the increasing the percep tion that psychotherapy is scientific insofar as it entails describing our services as the successful treatment of psychiatric diagnoses, may inadvertently lead many individuals to avoid the endeavor altogether.
52 APPENDIX A INFORMED CONSENT DOCUMENTS Study 1 (MTurk TM ) Please read this consent document carefully before you decide to participate in this study. You must be 18 years of age or older to participate. Purpose of the research study: You have been invited to participate in a research study. The pu rpose of this study is to gather some of your opinions about psychotherapy. If you chose to participate in this study, you will be asked to complete an online survey by carefully reading all survey materials and providing honest responses to each question. Time required: About 5 minutes. Risks, Benefits, and Compensation: There are no known risks or benefits involved in this study. If you choose to participate, you will earn $0.50 for use on Amazon.com through the MTurk TM payment system. Confidentiality: All of your responses will be held in confidence, and you will never be identified as a participant. No identifying information will be collected. Your IP address (a numerical identification tied to your Internet service provider) will not be known to the researchers, and will not be collected with your answers. There is a minimal risk that security of any online data may be breached, but since (1) no identifying information will be collected, (2) the online host (Qualtrics survey software) has SAS 70 Cer tification and meets the rigorous privacy standards imposed on health care records by the Health Insurance Portability and Accountability Act (HIPAA; see http://www.qualtrics.com/security statement), and (3) your data will be removed from the server soon after you complete the study, it is highly unlikely that a security breach of the online data will result in any adverse consequence for you. Voluntary participation: Your participation in this study is completely vol untary. You do not have to answer any questions that you do not wish to answer. You have the right to withdraw from the study at any time without consequence. Whom to contact if you have questions about the study: Ken Swan, PhD Candidate, Department of P sychology, University of Florida, email@example.com
53 Martin Heesacker, PhD: Department of Psychology, University of Florida, phone (352) 273 2137. Agreement: By choosing to respond to the questions in this survey, I am agreeing to the following statement: I have read the procedure described above, I voluntarily agree to participate in the procedure, I have received a copy of this description, and I am at least 18 years of age.
54 Study 2 (SocialSci) *Purpose of the research study*: You have been invited to participate in a research study. Our purpose is to gather some of your opinions about *psychotherapy*. If you chose to participate, you will be asked to complete an online survey by carefully reading all survey materials and providing honest responses to e ach question. *Time required*: About 10 minutes. *Risks, Benefits, and Compensation*: There are no known risks or benefits involved in this study. You will earn points for your SocialSci account for participating. *Confidentiality*: All of your res ponses will be held in confidence, and you will never be identified as a participant. No identifying information will be collected. Your IP address (a numerical identification tied to your internet service provider) will not be known to the researchers, an d will not be collected with your answers. The final part of this survey asks you to provide some general demographic information about yourself. This information is only used to describe your general characteristics, not to identify you as a person. Analy sis of answers will be in aggregate form and individual answers will not be published. There is a minimal risk that security of any online data may be breached, but since (1) roprietary software) was designed such that it is not possible to link personal survey results with any individual (see https://research.socialsci.com/docs/contents/147 irb_compliance for ved from the server soon after you complete the study, it is highly unlikely that a security breach of the online data will result in any adverse consequence for you. *Voluntary participation*: Your participation in this study is completely voluntary. Yo u do not have to answer any questions that you do not wish to answer. You have the right to withdraw from the study at any time without consequence. *Whom to contact if you have questions about the study*: Ken Swan, M.S., PhD Candidate, Department of Ps ychology, University of Florida, firstname.lastname@example.org
55 Martin Heesacker, PhD: Department of Psychology, University of Florida, phone (352) 273 2136. *Whom to contact about your rights as a research participant in the study*: This study has been approved by the Institutional Review Board at the University of Florida (IRB # 2012 U 1346): IRB02 Office, Box 112250, University of Florida, Gainesville, FL 32611 2250; phone 392 0433. *Agreement*: By choosing to respond to the questions in this survey, I am ag reeing to the following statement: I have read the procedure described above, I voluntarily agree to participate in the procedure, I have received a copy of this description, and I am at least 18 years of age.
56 APPENDIX B STUDY 1 SURVEY MATERIALS Welco me! We are truly thankful for your time. As you move through this short survey, please keep in mind that your responses will be strictly anonymous, having never been linked to your name or any other identifying information. Our research endeavors to find out how people think and feel about psychotherapy: the general process of addressing mental health concerns by talking with a psychologist or other mental health provider. More than 20 years of scientific research have led to the conclusion that psychother apy works quite well for those who use it. There is some debate among professionals, however, concerning how psychotherapy produces its benefits. Now, we would like you to read two short answers to the question of how psychotherapy works written for us b y two different licensed mental health professionals (psychologists). After carefully reading and thinking about each answer (imagine what that therapy would look like), please respond to the two questions that follow. Your deep reflection about these i ssues means a great deal to us and our research. First answer: [Randomized] At their core, all psychotherapies provide a confiding relationship with a therapist, in which you can safely discuss your problems with someone who will work in your best intere st. As that relationship develops, you'll both attempt to better understand the reasons for your troubles. The final step requires active involvement from both you and your therapist as you work to bring about a change in your life. How likely is it that you would schedule an appointment with this therapist if you believed you were having a mental breakdown? Very Likely Likely Somewhat Likely Undecided Somewhat Unlikely Unlikely Very Unlikely
57 Psychotherapy of this kind would not have value for a person li ke me. Strongly Agree Agree Somewhat Agree Neither Agree nor Disagree Somewhat Disagree Disagree Strongly Disagree If the people in your life (friends, family, co workers) found out that you were enrolled in therapy like this description, to what degree d o you believe that they would ... Not at all A little Some A lot A great deal ...react negatively to you? ...think bad things of you? ...see you as seriously disturbed? ...think of you in a less favorable way? ...think you posed a risk to others? Second answer: [Randomized] Psychotherapy begins with the goal of an accurate diagnosis. This in turn points the way to an explanation for your symptoms, and the best course of treatment. Then, your therapist can administer a set of specific therapeutic interventions designed to target your particular problem. The benefits of psychotherapy are due to your participation in these scientifically established therapy ingredients.
58 How likely is it that you would schedule an appointment with this therapist if you believed you were having a mental breakdown? Very Likely Likely Somewhat Likely Undecided Somewhat Unlikely Unlikely Very Unlikely Psychotherapy of this kind would not have value for a person like me. Strongly Agree Agree Somewh at Agree Neither Agree nor Disagree Somewhat Disagree Disagree Strongly Disagree If the people in your life (friends, family, co workers) found out that you were enrolled in therapy like this description, to what degree do you believe that they would ... Not at all A little Some A lot A great deal ...react negatively to you? ...think bad things of you? ...see you as seriously disturbed? ...think of you in a less favorable way? ...think you posed a risk to others? Please con tinue on to the next page.
59 Almost done! But first, just a quick check to make sure you were paying attention: Which of the following was part of one of the descriptions of how therapy works we showed you in this survey? Freudian therapy seems to work b est for treating panic attacks "a confiding relationship with a therapist, in which you can discuss your concerns with someone who will work in your best interest." "cognitive behavioral therapy works best for treating depression and anxiety disorders, bu t not for eating disorders." Please continue on to the next page.
60 This last section of demographic information is only used to describe your general characteristics, not to identify you as a person. Age: ____________________ Gender Male (1) Female (2) Racial identification (please select all that apply) American Indian or Alaska Native (1) Asian (2) Black or African American (3) Native Hawaiian or Other Pacific Islander (4) White (5) Some Other Race (6) Which of the following best matches how you iden tify yourself? Hispanic or Latino/Latina (1) Not Hispanic or Latino/Latina (2) Highest level of education completed 8th grade or less (1) 9th to 12th grade (2) High school graduate (3) Some college (4) Associate's degree (5) College graduate (6) Postgradu ate work/degree (7) Marital Status Married (1) Widdowed (2) Divorced (3) Separated (4) Never married (5) Living with partner (6)
61 Household income Less than $9,999 (1) $10,000 $19,999 (2) $20,000 $34,999 (3) $35,000 $49,999 (4) $50,000 $99,999 (5) $100,00 0 $149,999 (6) $150,000+ (7) Which geographic region best describes where you live in the US? Northeast (1) Midwest (2) South (3) West (4) Have you ever in your life seen a psychiatrist, psychologist, or social worker for counseling or therapy? [Yes/No] If you have ever in your life seen a psychiatrist, psychologist, or social worker for counseling or therapy, please indicate which of these two explanations of how therapy works best matches the kind of therapy you received (please choose all that apply) : At their core, all psychotherapies provide a confiding relationship with a therapist, in which you can safely discuss your problems with someone who will work in your best interest. As that relationship develops, you'll both attempt to better understand the reasons for your troubles. The final step requires active involvement from both you and your therapist as you work to bring about a change in your life Psychotherapy be gins with the goal of an accurate diagnosis. This in turn points the way to an explanation for your symptoms, and the best course of treatment. Then, your therapist can administer a set of specific therapeutic interventions designed to target your particul ar problem. The benefits of psychotherapy are due to your participation in these scientifically established therapy ingredients. Neither of these choices matches the kind of therapy I received.
62 APPENDIX C S ADDITIONAL SURVEY MATERIALS seek help through psychotherapy. Imagining that you were experiencing the problem listed below, which type of therapy would you prefer? T herapy A [Randomized] At their core, all psychotherapies provide a confiding relationship with a therapist, in which you can safely discuss your problems with someone who will work in to better understand the reasons for your troubles. The final step requires active involvement from both you and your therapist as you work to bring about a change in your life. Therapy B [Randomized] Psychotherapy begins with the goal of an accurate diag nosis. This in turn points the way to an explanation for your symptoms, and the best course of treatment. Then, your therapist can administer a set of specific therapeutic interventions designed to target your particular problem. The benefits of psychother apy are due to your participation in these scientifically established therapy ingredients. Therapy A Therapy B No Preference Neither Feelings of sadness, loss, guilt, or hopelessness that interfere with your everyday life for weeks or longer. The almost constant presence of worry or tension, even when there is little or no cause. Serious disturbances to your everyday diet, such as a strong urge to eat extremely small amounts of food or severely overeat.
63 The compulsive use of drugs or alcohol, despite its negative or dangerous effects on your daily life. A loss of contact with reality, such as false beliefs about what is taking place or who one is (delusions), or seeing or hearing things that aren't there (hallucinations). Great! Now, things get a bit tricky. We ask that for the rest of the questions on this page, you think about other people in psychotherapy, rather than yourself: Therapy A [Randomized] A t their core, all psychotherapies provide a confiding relationship with a therapist, in which you can safely discuss your problems with someone who will work in the reasons for your troubles. The final step requires active involvement from both you and your therapist as you work to bring about a change in your life. Other people should schedule an appointment with this therapist (Therapy A) if they believed they wer e having a mental breakdown. Strongly agree Agree Somewhat Agree Neither Agree nor Disagree Somewhat Disagree Disagree Strongly disagree
64 Psychotherapy of this kind (Therapy A) would NOT have value for other people Strongly agree Agree Somewhat Agree Neither Agree nor Disagree Somewhat Agree Disagree Strongly Disagree Therapy B [Randomized] Psychotherapy begins with the goal of an accurate diagnosis. This in turn points the way to an explanation for your symptoms, and the best course of treatment. Then, your therapist can administer a set of specific therapeutic interventions designed to target your particular problem. The benefits of psychotherapy are due to your participation in these scientifically established therapy i ngredients. Other people should schedule an appointment with this therapist (Therapy B) if they believed they were having a mental breakdown. Strongly agree Agree Somewhat Agree Neither Agree nor Disagree Somewhat Disagree Disagree Strongly di sagree Psychotherapy of this kind (Therapy B) would NOT have value for other people Strongly agree Agree Somewhat Agree Neither Agree nor Disagree Somewhat Agree Disagree Strongly Disagree
65 Which of these two approaches to therapy do you thin k that they author of this survey favors? At their core, all psychotherapies provide a confiding relationship with a therapist, in which you can safely discuss your problems with someone who will work in your best i nterest. As that relationship develops, you'll both attempt to better understand the reasons for your troubles. The final step requires active involvement from both you and your therapist as you work to bring about a change in your life Psychotherapy begins with the goal of an accurate diagnosis. This in turn points the way to an explanation for your symptoms, and the best course of treatment. Then, your therapist can administer a set of specific therapeutic interv entions designed to target your particular problem. The benefits of psychotherapy are due to your participation in these scientifically established therapy ingredients. Neither of these choices Before you started t his survey which of these types of therapy would you have expected to receive if you sought help from a psychologist ? At their core, all psychotherapies provide a confiding relationship with a therapist, in which y ou can safely discuss your problems with someone who will work in your best interest. As that relationship develops, you'll both attempt to better understand the reasons for your troubles. The final step requires active involvement from both you and your t herapist as you work to bring about a change in your life Psychotherapy begins with the goal of an accurate diagnosis. This in turn points the way to an explanation for your symptoms, and the best course of treatm ent. Then, your therapist can administer a set of specific therapeutic interventions designed to target your particular problem. The benefits of psychotherapy are due to your participation in these scientifically established therapy ingredients. Neither of these choices
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73 BIOGRAPHICAL SKETCH L. Ken Swan received his Ph.D. in psychology from the University of Florida in the summer of 2013. Subsequently, Ken obtained a faculty position in the University of Department of Psychology, where he will serve as a full time lecturer Ken also plans to pursue licensure as a mental health counselor and a new program of clinical research investigating the scientific and economic viability of providing supportive, common factors based psychotherapy to the socially marginalized and underprivileged on a large scale