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Susan L. Kenford, Ph.D.______Susan L A Dissertation Submitted to the Faculty of Xavier University in Partial Fulfillment of the Requirements for the Degree of Doctor of Psychology by Elizabeth A. Garcia, M.A. November 9, 2020 Approved: Morrie Mullins, Ph.D. Morrie Mullins, Ph.D. Chair, School of Psychology Susan L. Kenford, Ph.D._______ Susan L. Kenford, Ph.D. Dissertation Chair TREATMENT ENGAGEMENT IN A PSYCHOLOGY CLINIC 2 Effect of Help-Seeking Stigma, Perceived Symptom Severity, and Perceived Mattering on Treatment Engagement in a University Psychology Training Clinic TREATMENT ENGAGEMENT IN A PSYCHOLOGY CLINIC 3 Dissertation Committee Chair Susan L. Kenford, Ph.D. Associate Professor of Psychology Member Jennifer E. Gibson, Ph.D. Associate Professor of Psychology Member Nicholas L. Salsman, Ph.D., ABPP Associate Professor of Psychology TREATMENT ENGAGEMENT IN A PSYCHOLOGY CLINIC 4 Table of Contents Page Table of Contents………………………………………………………………………………….4 List of Tables……………………………………………………………………………...………5 List of Appendices………………………………………………………………………………...6 Abstract…….……………………………………………………………………………...………7 Dissertation……...………………………………………………………………………………...8 References………………………………..………………………………………………………46 Tables……………………………………………..…………………..……………………...…..55 Appendices…………………..………………………………………………………………...…61 Summary……………………………………………..………………………...……………...…77 TREATMENT ENGAGEMENT IN A PSYCHOLOGY CLINIC 5 List of Tables Table Page 1. Sample Demographics……………………………………………………………...…..129 2. Mean Scores of All Study Variables by Sample………………………………………………………………………….……….130 3. Perceived Likelihood of Pursuing Treatment and Source of Services……………...….131 4. Univariate Tests of Demographic Factors Relation to Treatment Engagement…....…..132 5. Univariate Logistic Regression Analyses of Theoretical Predictors and Treatment Engagement………………………………………………………………………....…..133 6. Multivariate Logistic Regression Analyses of Theoretical Predictors and Treatment Engagement………………………………………………………………….……...…..134 TREATMENT ENGAGEMENT IN A PSYCHOLOGY CLINIC 6 List of Appendices Appendix Page A. Demographics and Help-Seeking Behavior Questionnaire (DHSBQ)…………………135 B. Perceived Likelihood of Attending Therapy Sessions Questionnaire (PLATSQ)….......137 C. Perceived Likelihood of Attending Therapy Non-Clinical Questionnaire (PLATNQ). …………………………………………………………………………….138 D. Self-Stigma of Seeking Help Scale (SSOSH)…………………………...………….......139 E. Mattering to Others Questionnaire (MTOQ)…..………………………………...…..…141 F. Self-Appraisal of Illness Questionnaire-Revised (SAIQ-R)…………….……...………145 G. Outcome Questionnaire 45 (OQ-45)….……………………...………….……………...147 H. Treatment Engagement Capture Form (TECF)….……………..………………….…...148 I. IRB Approval….……………………………….….……………………………….…...149 J. Non-Clinical Participants’ Demographic and Study Variables by Subsample…….…...150 TREATMENT ENGAGEMENT IN A PSYCHOLOGY CLINIC 7 Abstract Despite the high rates of mental health concerns within the college population, treatment utilization remains low (American College Health Association [ACHA], 2018; Cadigan et al., 2019; Lipson & Lattie, 2019). The current study explored the impact of psychological help- seeking stigma, perceived symptom severity, and perceived mattering on treatment engagement within a university psychology training clinic. One hundred thirty-four clients completed study measures prior to their intake appointment. Treatment engagement was operationalized as attending at least 4 sessions of individual therapy within the first 60 days of beginning treatment. A secondary non-clinical sample (n = 112) was collected from the psychology participant pool at the same university. Clinical participants scheduled an average of 7.85 therapy sessions and attended an average of 6.42 therapy sessions; most (n =103) clients engaged in treatment. Results indicated clinical sample participants reported significantly lower help-seeking stigma, higher perceived symptom severity, and lower perceived mattering to others pretreatment compared to participants in the non-clinical sample. A significant inverse relation between mattering to others and help-seeking stigma was found in the non-clinical sample, p < .001, but not for the clinical sample, p = .44. A prediction model was built within the clinical sample using logistic regression with treatment engagement as the outcome variable. The final prediction model for the clinical sample included only one variable, perceived mattering to others, that showed a significant relation and increased odds of treatment engagement, β = .05, p = .01, OR = 1.04. These findings provide evidence that efforts to reduce premature termination within university clinics should focus on increasing perceived mattering to others. TREATMENT ENGAGEMENT IN A PSYCHOLOGY CLINIC 8 Effect of Help-Seeking Stigma, Perceived Symptom Severity, and Perceived Mattering on Treatment Engagement in a University Psychology Training Clinic Mental Health and Help-Seeking in the College Population A substantial number of college students experience mental health concerns. According to the 2018 American College Health Association annual national survey, depression and anxiety are the most prevalent mental health conditions in the college population and were reported, respectively, by 43% and 63% of respondents (ACHA, 2018). Not only are mental health concerns common, they appear to be increasing. For example, Lipson and Lattie (2019) found that the number of college students with lifetime mental health diagnoses increased from 21.9% in 2007 to 35.5% by 2017. Despite the high rates of mental health issues among college students, only a relatively small number of students who could benefit from mental health services actually receive mental health services (ACHA, 2018; Cadigan et al., 2019; Lipson & Lattie, 2019). For example, in a large-scale study of 155,026 students from 196 US college campuses, 26.9% screened positive for depression and 8.2% reported suicidal ideation on the PHQ-2 (Lipson & Lattie, 2019). Among the students who were depression-positive, only 53.3% reported receiving past-year treatment, defined as any therapy, counseling, and/or psychotropic medication Similarly, in a sample of 622 young adults (ages 18-23) recruited from a large metropolitan area in the Pacific Northwestern United States, fewer than half of participants (39.7%) who screened positive for depression on the Patient Health Questionnaire-9 (PHQ-9) reported having utilized any form counseling or outpatient treatment for mental health problems in the last 12 months (Cadigan et al., 2019). Such studies suggest that, at best, only about half of young adults who show active symptoms report any treatment; although disturbingly low, that rate may actually be an overestimate of mental health utilization as treatment utilization studies TREATMENT ENGAGEMENT IN A PSYCHOLOGY CLINIC 9 rarely capture the intensity of treatment. A major limitation of such studies is that although they document the number of actively depressed people who report at least one session of therapy and/or who took prescribed psychotropic medication at least once in the past 12 months, they do not capture the extent to which these people engaged or participated in treatment to a sufficient degree or at a level known to produce therapeutic effects. Understanding why college students who have access to no-cost treatment fail to take advantage of services requires a more comprehensive understanding of treatment-seeking behavior. A recurrent finding is that even when treatment is pursued, the dosage and duration are often insufficient to affect meaningful change. According to the Center for Collegiate Mental Health 2015 Annual Report, which included 79,331 college students participating in counseling services between 2014 and 2015, the average number of counseling sessions attended was 4.71 (including intake appointment). The modal number of sessions for this sample of college students was one. Likewise, in the general population, research indicates that the modal number of sessions for psychotherapy is one (Gibbons et al., 2011). Such findings give rise to the question of what factors might be serving to suppress both treatment seeking and subsequent engagement. Stigma Related to Seeking Psychological Help Although there are clear potential benefits to treatment-seeking, there can also be underappreciated psychological costs; one such cost appears to take the form of experienced stigma (Rosenfield, 1997). Stigma is defined as experiencing a decrease in self-esteem related to membership in a particular social group (Link, 1987; Rosenfield, 1997). According to the modified labeling theory of mental illness (Link 1987), over time and with social experience, people develop negative ideas about what the general public thinks about people with mental TREATMENT ENGAGEMENT IN A PSYCHOLOGY CLINIC 10 illness. Then, when an individual seeks treatment and/or is diagnosed with a mental disorder, all the negative cultural ideas associated with mental illness (e.g., dangerous, incompetent) become personally applicable and can fuel a negative emotional experience within the individual. The individual with mental illness may have the expectation that they will be rejected by others, triggering defensive behaviors such as withdrawing from social interactions or concealing their treatment history. These defensive behaviors appear to be counterproductive in that they are associated with negative outcomes such as feelings of demoralization and higher rates of unemployment (Link, 1987). There is an important
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