SOME DESCRIPTIONS OF THERAPY ARE LESS ...

Running head: SOME DESCRIPTIONS OF THERAPY ARE LESS STIGMATIZING

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In press at Stigma and Health APA copyright notice: This article may not exactly replicate the final version published in the APA journal. It is not the copy of record.

Are Some Descriptions of Psychotherapy Perceived as More (or Less) Stigmatizing than Others? A Preliminary Investigation Lawton K. Swan and Martin Heesacker University of Florida Kelly M. King University of North Carolina at Greensboro

Author Note Lawton K. Swan, Department of Psychology, University of Florida; Martin Heesacker, Department of Psychology, University of Florida; Kelly M. King, Department of Counseling and Educational Development, University of North Carolina at Greensboro. Correspondence concerning this article should be addressed to Lawton K. Swan, 945 Center Drive, P.O. Box 112250, Gainesville, FL, 32611 (e-mail: [email protected]).

SOME DESCRIPTIONS OF THERAPY ARE LESS STIGMATIZING

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Abstract Researchers in the United States have documented a sizable correlation between people’s perceptions of public mental illness stigma on the one hand and their willingness to pursue psychological treatment on the other—as expectations of stigmatization rise, attitudes toward seeking professional help (e.g., psychotherapy) tend to grow more negative. In this article, we raise the possibility that some descriptions of psychotherapy—namely, descriptions that underscore the process of diagnosis and the application of specific remedial interventions—may heighten potential clients’ concerns about stigmatization and degrade help-seeking attitudes more than others (e.g., the supportive relationship between client and clinician). Two brief onlinesurvey-based experiments provided preliminary tests of this hypothesis. In Study 1, we presented adults from across the United States (N = 293) with hypothetical therapists who emphasized either (a) selecting the correct psychological treatment for a client’s particular problem or (b) cultivating a strong therapeutic alliance when conducting sessions. Participants reported more favorable attitudes toward seeking services in the alliance-centric condition (d = .35), an effect mediated by reductions in perceived public help-seeking-related stigma. Study 2 (N = 391) added to the (a) treatment and (b) alliance emphasis conditions (c) a baseline group (who received no emphasis statement before rating their help-seeking attitudes and public stigma perceptions) and (d) a combination group (who received a statement with a joint emphasis on both the alliance and specific treatments). Results again favored the alliance emphasis, suggesting (tentatively) that practitioners should highlight the relational elements of psychotherapy when describing their services to the public. Keywords: help-seeking attitudes, psychiatric diagnosis, psychotherapy, therapeutic alliance


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Are Some Descriptions of Psychotherapy Perceived as More (or Less) Stigmatizing than Others? A Preliminary Investigation In the United States, the specter of public stigmatization—the demoralizing stereotypes, prejudices, and acts of discrimination that communities often direct toward their undesirably marginal members—prevents hundreds of thousands of mentally ill adults from pursuing readilyavailable psychological treatments every year (Corrigan, 2004; SAMSA, 2013). Three decades of scientific enquiries into this relationship between public-stigma-awareness on the one hand and professional-help-seeking reluctance on the other have witnessed significant progress, including the revelation of its mediating mechanism (when people internalize the proposition that engaging psychological services bespeaks inferiority, the instinctive human drive to maintain a positive self-image often trumps the desire for symptom relief; e.g., Vogel, Bitman, Hammer, & Wade 2013) and a growing catalog of stigma-reducing interventions (e.g., Lannin et al., 2013). Nevertheless, there is much empirical terrain left to explore. One of these largely uncharted regions concerns the amount of public help-seeking stigma—the degree to which one expects negative reactions from friends and family for engaging psychological services—that potential clients associate with different elements of the treatment process. When researchers measure the effects of treatment-related public-stigma expectations on help-seeking attitudes, the self-report questionnaires that they employ most often cast “professional help” in broad and indefinite terms. Fischer and Farina’s (1995) popular ‘Attitudes toward Seeking Professional Psychological Help: Short Form’ (ATSPPH-SF) scale, for instance, asks respondents to consider notions such as “professional attention” and “psychological help” without offering elaboration or context. Yet it seems quite likely that some


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descriptions of the experience would activate or reduce concerns about stigmatization more than others. Consider the case of psychotherapy, which owes at least as much of its demonstrable efficacy to generic common factors (e.g., supportive patient-provider relationships) as it does to the application of specific-psychopathology-targeting interventions (e.g., see Laska, Gurman, & Wampold, 2014; Norcross, 2011; and Wampold & Imel, 2015). Both elements typify real-world, evidence-based psychotherapy practice, but there is good reason to suspect that potential clients associate the latter with relatively more public stigma. Viewed from the perspective of modified labeling theory (Link et al., 1989), the receipt of a psychiatric diagnosis—and its corresponding remedial treatments—acts as a self-stigma catalyst, setting into motion a cascade of threats to the branded individual’s sense of self-worth (Corrigan, 2007; Kroska & Harkness, 2008). Thus, descriptions of psychotherapy which highlight the matching of specific techniques to particular problems (often deemed the psychological treatments approach; Barlow, 2004), might rouse fears of stigmatization and degrade help-seeking attitudes more so than descriptions which focus only on non-specific (non-pathology-based) aspects. Conversely, one non-specific factor in particular, the formation of a positive working alliance with a service provider, predicts reductions in self-stigma and a client’s willingness to continue seeking psychological help (Wade et al., 2011), and a wealth of evidence from communication science suggests that the mere anticipation of a warm interpersonal bond may confer similar advantages (e.g., Honeycutt, 2003). Thus, descriptions of psychotherapy with an emphasis on the therapeutic alliance conceivably might reduce public stigma expectations and improve help-seeking attitudes. We sought preliminary evidence for these complementary possibilities in two brief experiments.


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Study 1 First, we presented a sample of adults from across the United States with fictional therapists who emphasized either (a) selecting the correct psychological treatment or (b) cultivating a strong therapeutic alliance when conducting sessions. We predicted that participants would report more negative attitudes toward seeking help from psychotherapy framed by the psychological treatments focus (Hypothesis 1), and that differences in anticipated stigmatization by others would mediate that preference (Hypothesis 2). Methods We invited a convenience sample of 300 users of Amazon.com’s Mechanical Turk (MTurk) service to fill out a short online questionnaire: Mage = 30.2; 63% identified as “male” and 80.2% as “Caucasian” (see this article’s supplemental materials for more detailed information about participants’ demographic characteristics, the full text of our survey, and a link to our datasets). Registered (self-selected) MTurk users serve as an on-demand workforce for simple computer-based tasks that require human intelligence, including social science research participation. Studies have shown that MTurk users better represent the United States population than convenience samples of undergraduates, produce high-quality survey data (Buhrmester, Kwang, & Gosling, 2011), and report incidences of depression, anxiety, and trauma exposure that approximate the prevalence of these problems in the general population (Shapiro, Chandler, & Mueller, 2013). Seven participants failed an instrumental attention check (see our supplemental materials), leaving 293 cases for analysis. After furnishing a broad definition of psychotherapy (a general term for addressing mental health problems by talking with a licensed professional, often called "talk therapy"), we asked participants to read two statements, ostensibly generated by real therapists, penned in


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response to an open-ended question prompt: When I conduct psychotherapy, I focus most of my energy on __________. The first, reflecting a psychological treatments focus, read: selecting and applying the correct psychological treatment for my client's particular problem. The second, reflecting an alliance focus, read: fostering an atmosphere in which my clients feel heard, understood, and respected. We adapted the wording for the latter from Duncan et al.’s (2003) session rating scale, designed to measure alliance strength. All participants received both descriptions, each presented on a separate survey page (the order of appearance was counterbalanced at random). Following each emphasis statement, participants rated on seven-point Likert-type scales (a) the likelihood that they would schedule an appointment with each therapist if they believed they were having a mental breakdown, and (b) whether they believed that the type of psychotherapy offered by each therapist would have value for a person like them. In other words, each participant received this two-question set twice, once for each therapist. Each item reﬂects one of the two higher-order factors from the ATSPPH-SF (see Elhai, Schweinle, & Anderson, 2008). In this study, Cronbach’s α = .78 for the two-item total following the treatment emphasis, and α = .76 for the two-item total following the alliance emphasis. Similarly (and subsequently), participants completed Vogel et al.’s (2009) five-item Perceptions of Stigmatization by Others for Seeking Help scale—which captures respondents’ perceptions of the likelihood that the people they interact with would enact stigmatizing behaviors if the respondent were to seek professional psychological help—once for each emphasis (in this study, α’s = .93 and .92 for the treatment and alliance emphases, respectively).


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Results and Discussion All dependent variables appeared suitably normal for parametric analyses (e.g., absolute skewness and kurtosis values < 1.3). Because no variable contained more than 4% missing data (10 participants had missing data in at least one criterion), we used only fully available cases. Consistent with Hypothesis 1, a paired-samples t-test revealed that participants reported significantly more positive help-seeking attitudes toward the alliance description (M = 10.43, SD = 2.61) than the treatments description (M = 9.54, SD = 2.71), t(289) = 4.27, p < .001, d = .35. To test for mediation, we followed Judd, Kenny, and McClelland’s (2001) procedure, regressing the absolute difference between participants’ attitudes toward seeking help from each therapist onto the difference between participants’ stigma ratings for each therapist. The model was significant, F(2, 281) = 37.06, p < .001, R2 = .21. Consistent with Hypothesis 2, the difference between participants’ stigma scores significantly predicted differences in help-seeking attitudes (β = -.46, p < .001), indicating that perceptions of stigmatization by others mediated the help-seeking attitude difference (controlling for the main effect of stigma on help-seeking attitudes; see Judd et al., 2001 for full procedural details and a justification for this approach to mediation). A non-significant model intercept (B = .51, p = .29) indicated full mediation. Participants who had never been psychotherapy clients responded to our manipulations similarly to the overall sample (see Table S2 in our supplemental materials), though the mean differences were considerably larger among those without personal psychotherapy experience. Thus, these preliminary results indeed suggest that people do indeed associate some descriptions of psychotherapy with more (or less) public stigma than others. But which is it? Relative to how the public thinks about psychotherapy in the absence of any therapist-individuating information, did the treatments emphasis elicit more stigma anticipation, or did the alliance emphasis elicit


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less? Because participants in Study 1 were not randomly assigned to each condition (i.e., it did not include a control condition), Study 1’s results cannot provide an answer to this important question. We designed Study 2 to address this limitation. Study 2 Study 2 comprised a between-participant design, adding to the (a) treatment and (b) alliance emphasis conditions (c) a baseline group (who received no emphasis statement before rating their help-seeking attitudes and stigma perceptions) and (d) a combination group (who received a statement with a joint emphasis on both the alliance and specific treatments). The combination condition allowed us to explore—without an a priori hypothesis—the possibility that the alliance focus is positively potent enough to override the stigmatizing effects of a mention of psychological treatments (should we find that the treatments focus does in fact elicit greater perceptions of public stigmatization relative to baseline). This approach also presented us with the opportunity to analyze our data using a fully-crossed 2 (whether or not the alliance was emphasized) x 2 (whether or not treatment was emphasized) design, thereby allowing us to isolate the unique effect of each emphasis. Study 2 also tested the assumption that our findings hold true specifically for those who have never been psychotherapy clients. Method Study 2 duplicated most of Study 1’s methods with a new sample of MTurk users (N = 391 after removing nine who failed the attention check; Mage = 30.5; 60% identified as “male” and 81.0 % as “Caucasian”). The critical difference was in randomization—participants in Study 2 read only one of three therapist emphasis statements (treatment, alliance, or a combination), or no therapist information at all (four experimental conditions in total).


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Results and Discussion Again, both dependent variables appeared suitably normal for parametric analyses (e.g., absolute skewness and kurtosis values < 1.0). Finding no more than 4% missing data (16 participants had missing data in at least one criterion), we again used only complete cases. When comparing individual means, we applied Bonferroni alpha-adjustment. A four (emphasis condition: treatment, alliance, combination, or baseline) by two (participant prior experience as a therapy client, yes or no) analysis of variance (ANVOA) revealed significant main effects of emphasis condition [F(3, 376) = 11.00, p < .001] and therapy experience [F(1, 376) = 16.69, p < .001] on help-seeking attitudes (prior clients reported more positive attitudes), but no significant interaction between the two [F(3, 376) = 2,99, p = .74]. When we decomposed this non-significant interaction by comparing means separately for previous clients and non-clients, we found that participants who had never been psychotherapy clients responded similarly to the overall sample (i.e., the pattern of statistically significant differences between experimental conditions is invariant between previous clients and nonclients; see Table 1). Replicating the results of Study 1, planned contrasts (individual mean comparisons) revealed that participants overall reported significantly more positive attitudes toward seeking help from the alliance-focused therapist than from the treatments-focused therapist, p < .001, d = .46. Compared to the baseline condition, only the alliance (d = .58) and combination (d = .48) conditions emerged as significantly different (more favorable, p’s < .01) for the help-seeking attitudes criterion. That is, participants did not report more negative attitudes toward the treatment-focused therapist relative to their baseline counterparts (p = .10, d = .29 in the direction of more favorable attitudes toward the treatment focus). The same pattern emerged


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when we instead analyzed the data using a 2 (whether or not the alliance was emphasized) x 2 (whether or not treatment was emphasized) ANOVA: across levels of prior psychotherapy experience, we observed a main effect of the alliance factor [F(1, 381) = 27.12, p < .001], but not the treatment factor [F(1, 381) = .14, p = .71]. It could be that the treatments focus does not exacerbate stigma fears insomuch as it simply confirms them, although our data cannot provide direct evidence for this speculation. Compared to the combination condition, only the baseline group reported significantly lower help-seeking attitudes (p < .05, d = .48), though the pattern of effect sizes suggested to us that the pairing of both foci resulted in a middle ground—slightly more negative attitudes toward the combination emphasis than toward the alliance emphasis alone (d = .27); and slightly more positive attitudes toward the combination emphasis than toward the treatment emphasis alone (d = .18). However, these small effect sizes may simply reflect measurement error. Finally, returning to the overall sample, we sought to replicate our mediational finding from Study 1—that perceived stigmatization from friends and family mediates the effect of experimental condition (alliance versus treatment) on help-seeking attitudes. Indeed, a bootstrapped indirect effect test (5,000 samples; Preacher and Hayes, 2008; a different approach to mediation analysis to the one we utilized in Study 1) supported mediation [bias corrected 95% confidence interval = 0.06 through 0.53]. General Discussion Beyond suggesting an answer to our opening question, these preliminary results entice a simple strategy for narrowing the gap between the number of people who would benefit from psychotherapy and the number of people who pursue it: when advertising to the public, therapists could advertise the alliance. The presence of a therapeutic alliance in our fictional therapists’


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emphasis statements had a clear impact on participants’ self-reported attitudes toward pursuing mental health services. However, the question of why our participants exhibited this strong preference for the alliance emphasis—evident in both help-seeking attitudes and stigma perceptions—begs further study. To our surprise, we failed to support our theoretically-derived prediction that the mention of specific psychological treatments would intensify stigma concerns via the desire not to be labelled as mentally ill. Rather, something about the alliance emphasis, perhaps the mental simulation of a positive interpersonal encounter, actively decreased participants’ stigma perceptions below baseline. Exploring the mechanism driving this apparent alliance-preference effect represents a potential avenue for future research. We also hope that researchers will attempt to replicate and increase the external validity of our results by (a) utilizing more demographically representative samples; (b) contrasting the many other distinctive aspects of various treatment options in public-forum descriptions, and especially the ways in which these descriptions may or may not influence stigma fears directly; (c) varying the wordings of alliance- and treatment-centric descriptions, and especially in the interest of controlling for other extraneous differences between them (e.g., treatment decisions occur early on and focuses on the therapist, whereas the alliance is an ongoing process and focuses on both therapist and client); (d) including a within-subjects measure of help-seeking attitudes and expectations of stigmatization before (pre-test) and after (post-test) the presentation of a psychotherapy description; and (e) studying the effects of these emphasis shifts organically— will emphasizing the alliance increase help-seeking behaviors (e.g., as measured by increases in scheduled appointments)? Several other limitations of the present study should be addressed in subsequent investigations as well, such as the wide confidence band around the stigma mediation effect that


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we reported in Study 2 (future studies should attempt to isolate, understand, and minimize the sources of this variability) and our use of a psychometrically-limited (abridged) indicator of help-seeking attitudes (the wording of which may have unduly influenced our results). In the meantime, we submit the following tentative conclusion to our preliminary foray: mental health professionals of all theoretical persuasions trade on their ability to foster a strong patientprovider relationship (Norcross, 2011)—saying so might encourage more people to seek help when they need it.


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References Barlow, D. H. (2004). Psychological treatments. American Psychologist, 59, 869-878. http://dx.doi.org/10.1037/0003-066X.59.9.869 Buhrmester, M., Kwang, T., & Gosling, S. D. (2011). Amazon’s Mechanical Turk: A new source of inexpensive, yet high-quality data? Perspectives on Psychological Science, 6(1), 3-5. http://dx.doi.org/10.1177/1745691610393980 Corrigan, P. W. (2004). How stigma interferes with mental health care. American Psychologist, 59, 614–625. http://dx.doi.org/10.1037/0003-066X.59.7.614 Corrigan, P. W. (2007). How clinical diagnosis might exacerbate the stigma of mental illness. Social Work, 52(1), 31-39. http://dx.doi.org/10.1093/sw/52.1.31 Duncan, B. L., Miller, S. D., Sparks, J. A., Claud, D. A., Reynolds, L. R., Brown, J., & Johnson, L. D. (2003). The session rating scale: Preliminary psychometric properties of a “working” alliance measure. Journal of Brief Therapy, 3(1), 3-12. Elhai, J. D., Schweinle, W., & Anderson, S. M. (2008). Reliability and validity of the Attitudes Toward Seeking Professional Psychological Help-Short Form. Psychiatry Research, 159(3), 320-329. http://dx.doi.org/10.1016/j.psychres.2007.04.020 Fischer, E. H., & Farina, A. (1995). Attitudes toward seeking professional psychological help: A shortened form and considerations for research. Journal of College Student Development, 36, 368–373. doi:10.1016/j.psychres.2007.04.020 Honeycutt, J. M. (2003). Imagined interactions: Daydreaming about communication. Cresskill, NJ: Hampton.


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Judd, C. M., Kenny, D. A., & McClelland, G. H. (2001). Estimating and testing mediation and moderation in within-subject designs. Psychological Methods, 6(2), 115-134. http://dx.doi.org/10.1037/1082-989X.6.2.115 Kroska, A., & Harkness, S. K. (2008). Exploring the role of diagnosis in the modified labeling theory of mental illness. Social Psychology Quarterly, 71(2), 193–208. http://dx.doi.org/10.1177/019027250807100207 Lannin, D. G., Guyll, M., Vogel, D. L., & Madon, S. (2013). Reducing the stigma associated with seeking psychotherapy through self-affirmation. Journal of Counseling Psychology, 60(4), 508-519. doi: 10.1037/a0033789 Laska, K. M., Gurman, A. S., & Wampold, B. E. (2014). Expanding the lens of evidence-based practice in psychotherapy: A common factors perspective. Psychotherapy, 51, 467– 481. http://dx.doi.org/10.1037/ a0034332 Link, B., Cullen, F., Struening, E., Shrout, P., & Dohrenwend, B. (1989). A modified labeling theory approach to mental disorders: An empirical assessment. American Sociological Review, 54, 400–423. http://dx.doi.org/10.2307/2095613 Norcross, J. C. (Ed.). (2011). Psychotherapy relationships that work (2nd ed). New York: Oxford University Press. Preacher, K. J., & Hayes, A. F. (2008). Asymptotic and resampling strategies for assessing and comparing indirect effects in multiple mediator models. Behavior Research Methods, 40, 879–891. doi: 10.3758/BRM.40.3.879 Shapiro, D. N., Chandler, J., & Mueller, P. A. (2013). Using Mechanical Turk to study clinical populations. Clinical Psychological Science, 1(2), 213-220. doi:10.1177/2167702612469015


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Substance Abuse and Mental Health Services Administration (SAMSA). (2014) Results from the 2013 National Survey on Drug Use and Health: Mental Health Findings, NSDUH Series H49, HHS Publication No. (SMA) 14-4887. Rockville, MD. Retrieved from http://www.samhsa.gov/data/sites/default/files/NSDUHmhfr2013/NSDUHmhfr2013.pdf Vogel, D. L., Bitman, R. L., Hammer, J. H., & Wade, N. G. (2013). Is stigma internalized? The longitudinal impact of public stigma on self-stigma. Journal of Counseling Psychology, 60(2), 311-316. doi: 10.1037/a0031889 Vogel, D. L., Wade, N. G., & Ascheman, P. L. (2009). Measuring perceptions of stigmatization by others for seeking psychological help: Reliability and validity of a new stigma scale with college students. Journal of Counseling Psychology, 56(2), 301–308. doi:10.1037/a0014903 Wade, N. G., Post, B. C., Cornish, M. A., Vogel, D. L., & Tucker, J. R. (2011). Predictors of the change in self-stigma following a single session of group counseling. Journal of Counseling Psychology, 58(2), 170-182. doi:10.1037/a0022630 Wampold, B. E., & Imel, Z. E. (2015). The great psychotherapy debate: The research evidence for what works in psychotherapy (2nd ed.). New York, NY: Routledge

SOME ASPECTS OF PSYCHOTHERAPY ARE LESS STIGMATIZING

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Table 1 Participants’ Attitudes toward Seeking Psychotherapy Framed by Various Emphases (Study 2) (Baseline) M SD(n) 8.87a 3.13(98)

Treatment Alliance Combination M SD(n) M SD(n) M SD(n) 9.84ab 2.65(92) 10.99c 2.33(105) 10.31bc 2.67(89)

Full Sample Previous Clients 9.60a 3.33(42) 10.41ab 1.82(27) 11.32b 1.89(44) 10.98ab 2.04(44) NonClients 8.14a 2.84(56) 9.28ab 2.87(65) 10.66c 2.57(61) 9.64bc 3.05(45) Note. Participants (N = 391 MTurk users) reacted to a fictional therapist who emphasized (a) selecting the correct psychological treatment, (b) cultivating a strong therapeutic alliance, (c) or a combination of the two (a fourth “baseline” group received no emphasis). The criterion—a measure of help-seeking attitudes—ranged between 2 and 14, with higher scores indicating more positive attitudes. Means with different subscripts within each row differed significantly at p < .05, after Bonferroni alpha adjustment. Only the alliance and combination emphases consistently improved attitudes relative to a baseline (no description) condition in this between-participant design. This trend held up with only minor differences (in statistical significance, not direction) when we substituted a measure of perceptions of stigmatization as the dependent variable.

Supplemental Materials

Are Some Descriptions of Psychotherapy Perceived as More (or Less) Stigmatizing than Others? A Preliminary Investigation

Table S1 Sample Characteristics in Study 1 (N = 293) and Study 2 (N = 391) Study 1 % (n)

Study 2 % (n)

Measure Measure Age Ethnic Identification 18-24 33.8 (99) 30.7 (120) Hispanic 25-34 42.7 (125) 43.7 (171) Household income 35-44 9.9 (29) 15.9 (62) Less than $9,999 45-54 6.5 (19) 6.9 (27) $10,000-$19,999 55-64 4.4 (13) 2.0 (8) $20,000-$34,999 65-74 0.7 (2) 0.8 (3) $35,000-$49,999 Gender $50,000-$99,999 Female $100,000-$149,999 36.9 (108) 38.9 (152) Male 62.8 (184) 60.9 (238) $150,000+ Education Region 12th grade or less 1.3 (4) 0.5 (2) Northeast High school graduate 11.3 (33) 11.5 (45) Midwest Some college 39.6 (116) 36.1 (141) South Associate degree 8.5 (25) 6.4 (25) West College graduate 32.4 (95) 35.8 (140) Marital Status Postgraduate work/degree 6.5 (19) 9.7 (38) Married Racial Identificationa Never married Asian 13.7 (40) 10.0 (39) Living with partner Black/African American 4.4 (13) 6.6 (26) Divorced Native American/Alaska Native 2.0 (6) 0.8 (3) Separated Native Hawaiian/Pacific Islands Widowed 1 (3) 0.5 (2) White 80.2 (235) 80.8 (316) Therapy Client? Other 3.1 (9) 4.1 (16) Yes (Past/Present) Note. Due to missing data on demographic items, many totals fail to reach 100%. a Participants were allowed to choose more than one racial identification category.

Study 1 % (n)

Study 2 % (n)

7.8

(23)

6.9

(27)

11.6 11.9 18.8 14.7 34.1 7.2 1.4

(34) (35) (55) (43) (100) (21) (4)

8.7 11.8 24.3 17.1 27.4 7.2 3.6

(34) (46) (95) (67) (107) (28) (14)

25.3 23.9 25.6 25.3

(74) (70) (75) (74)

21.2 24.6 29.7 24.4

(83) (96) (116) (95)

28.3 52.9 12.6 4.4 1.0 0.3

(83) (155) (37) (13) (3) (1)

27.6 53.7 13.0 3.8 1.3 0.5

(108) (210) (51) (15) (5) (2)

40.6

(119)

40.4

(158)

Table S2 Participants’ Attitudes toward Seeking Psychotherapy Framed by Different Emphases (Study 1) Treatment Full Sample Previous Clients

Alliance

M 9.54a

SD(n) 2.71 (290)

M 10.43b

SD(n) 2.61(290)

9.48a

2.75(118)

10.25b

2.75(118)

Non-Clients 9.58a 2.69(172) 10.56b 2.52(172) Note. Participants (N = 293 MTurk users) reacted to fictional therapists who emphasized (a) selecting the correct psychological treatment, or (b) cultivating a strong therapeutic alliance (all participants read both therapy descriptions; order of presentation was counterbalanced). The criterion—a measure of help-seeking attitudes—ranged between 2 and 14, with higher scores indicating more positive attitudes. Means with different subscripts within each row differed significantly at p < .05 (dependent-samples t-tests).

Survey Materials Study 1 Welcome! We are truly thankful for your time. We're interested in how people think and feel about psychotherapy, a general term for treating mental health problems by talking with a licensed professional (often called "talk therapy"). In this study, we're specifically testing the possibility that people have more sophisticated opinions about psychotherapy and mental health professionals than social scientists typically imagine. On the next page, we'll ask you to answer some questions about your impressions of and attitudes toward two real, practicing therapists. The exact piece(s) of information about these two therapists you'll receive will be randomly selected by the survey software from a large bank of data we've collected over the last several years. It shouldn't take more than about 6 minutes of your time. Your randomly selected piece of information: Each therapist we've surveyed was asked to answer this question: "When I conduct psychotherapy, I focus most of my energy on __________." First Therapist: Answer: fostering an atmosphere in which my clients feel heard, understood, and respected. 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 with this therapist would NOT have value for a person like 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 with this professional, to what degree do you believe that they would ... Not at all

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Just one more. We know this isn't much to go on, but please try your best to use this small bit of information as a guide: Second Therapist: Answer: selecting and applying the correct psychological treatment for my client's particular problem.

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 with this therapist would NOT have value for a person like 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 with this professional, to what degree do you believe that they would ... Not at all

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Just a quick check to make sure you were paying attention: Which of the following was NOT part of one of the answers you read on the previous page?  understanding the roots of my clients' troubles in childhood.  selecting the correct psychological treatment for my client's particular problem.  fostering an atmosphere in which my clients feel heard, understood, and respected.

Age: ________________________ Gender  Male  Female Racial identification (please select all that apply)  Native American or Alaska Native  Asian  Black or African-American  Native Hawaiian or Other Pacific Islander  White  Some Other Race Which of the following best matches how you identify yourself?  Hispanic or Latino/Latina  Not Hispanic or Latino/Latina Highest level of education completed  8th grade or less  9th to 12th grade  High school graduate  Some college  Associate's degree  College graduate  Postgraduate work/degree

Marital Status  Married  Widowed  Divorced  Separated  Never married  Living with partner Household income  Less than $9,999  $10,000-$19,999  $20,000-$34,999  $35,000-$49,999  $50,000-$99,999  $100,000-$149,999  $150,000+ Which geographic region best describes where you live in the US?  Northeast  Midwest  South  West Have you ever in your life seen a psychologist, psychiatrist, or other mental health professional for counseling or psychotherapy?  Yes  No

Study 2 Welcome! We are truly thankful for your time. We're interested in how people think and feel about psychotherapy, a general term for treating mental health problems by talking with a licensed professional (often called "talk therapy"). In this study, we're specifically testing the possibility that people have more sophisticated opinions about psychotherapy and mental health professionals than social scientists typically imagine. On the next page, we'll ask you to answer some questions about your impressions of and attitudes toward a real, practicing therapist. The exact piece(s) of information about this therapist that you will receive have been randomly selected by the survey software from a large bank of data we've collected over the last several years. Your randomly selected piece of information: *** Each therapist we've surveyed was asked to complete this sentence: "When I conduct psychotherapy, I focus most of my energy on ..." Answer: [fostering an atmosphere in which my clients feel heard, understood, and respected] [selecting and applying the correct psychological treatment for my client’s particular problem.]

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 with this therapist would NOT have value for a person like 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 with this professional, to what degree do you believe that they would ... Not at all

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Just a quick check to make sure you were paying attention: Which of the following answers did you read on the previous page?  understanding the roots of my clients' troubles in childhood.  selecting the correct psychological treatment for my client's particular problem.  fostering an atmosphere in which my clients feel heard, understood, and respected. Age Gender  Male  Female

Racial identification (please select all that apply)  Native American or Alaska Native  Asian  Black or African-American  Native Hawaiian or Other Pacific Islander  White  Some Other Race Which of the following best matches how you identify yourself?  Hispanic or Latino/Latina  Not Hispanic or Latino/Latina Highest level of education completed  8th grade or less  9th to 12th grade  High school graduate  Some college  Associate's degree  College graduate  Postgraduate work/degree

Marital Status  Married  Widowed  Divorced  Separated  Never married  Living with partner Household income  Less than $9,999  $10,000-$19,999  $20,000-$34,999  $35,000-$49,999  $50,000-$99,999  $100,000-$149,999  $150,000+ Which geographic region best describes where you live in the US?  Northeast  Midwest  South  West Have you ever in your life seen a psychologist, psychiatrist, or other mental health professional for counseling or psychotherapy?  Yes  No

Dataset Download link (SPSS format): https://osf.io/xeb2q/