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 and empirically supported distinction between public stigma and self-stigma (Corrigan, 2004; Corrigan et al., 2006). Public stigma includes the negative attitudes and beliefs of the general public toward individuals within a particular category—e.g., with mental illness (Corrigan, 2004). In contrast, self-stigma is the application of negative attitudes and beliefs to oneself. In order to experience self-stigma, an individual must be aware of the stereotypes attached to a stigmatized group, agree with them and then apply these stereotypes to the self (Corrigan et al., 2009). Of the two, self-stigma appears to be more detrimental and predictive of negative outcomes. For example, research indicates that the effect of public stigma on psychological help-seeking is mediated by self-stigma, or the person’s internalization of public stigma related to mental illness (Vogel et al., 2007).
A growing body of work has investigated how self-stigma may influence psychological help-seeking. Vogel et al. (2006) developed the Self-Stigma of Seeking Help Scale (SSOSH), which is the first measure of self-stigma directly related to seeking psychological help. Results suggest that the SSOSH uniquely predicts help-seeking attitudes and help-seeking intent above and beyond sex, anticipated risks, anticipated benefits, and—importantly—public stigma (Vogel TREATMENT ENGAGEMENT IN A PSYCHOLOGY CLINIC 11 et al., 2006); college students with higher scores on the SSOSH demonstrated less positive attitudes toward psychological help-seeking and less intention to seek psychological treatment.
Further, research suggests college students’ self-stigma prior to treatment influences their treatment seeking behaviors at a later time point (Vogel et al., 2006); specifically, students with lower SSOSH scores were more likely to report seeking psychological services at two-month follow-up. Although Vogel et al. (2006) provides robust evidence for the importance of self- stigma, one methodological limitation is help-seeking behavior was based on self-report rather than behavioral or observational data.
Perceived Symptom Severity
As reviewed, research suggests a person must label themselves as a member of a negatively stereotyped group (e.g., people with mental illness) in order to experience the stigma related to that group (Corrigan, 2004; Corrigan et al., 2009; Vogel et al., 2007). One important way this labeling occurs is through individuals’ recognition that their experiences are symptoms of mental illness, often referred to as insight (Marks et al., 2000). Insight has been defined as a person’s awareness of their illness-related issues (Marks et al., 2000). Insight also appears associated with risk for self-stigma, as individuals who report greater symptom severity have shown higher levels of internalized stigma (Livingston & Boyd, 2010; Lysaker et al., 2013).
Additionally, research suggests that people with severe mental illness and minimal insight may be less likely to engage in help-seeking behaviors and, if they are connected to treatment, less likely to be treatment adherent (Lien et al., 2017; Sirey et al., 2001). In fact, research indicates that perceived symptom severity is a more important predictor of treatment adherence than either objective symptom levels (e.g., Center for Epidemiological Studies Depression Scale score) or clinician rated symptom severity (Bonabi et al., 2016; Sirey et al., 2001). In other words, it TREATMENT ENGAGEMENT IN A PSYCHOLOGY CLINIC 12 appears that individuals’ subjective sense of distress is what compels treatment decisions and underscores the importance of studying perceived symptom severity and subjective awareness of psychological dysfunction.
One readily available tool developed for community use to assess insight is the Self-
Appraisal of Illness Questionnaire (SAIQ; Marks et al., 2000). The SAIQ is a self-report measure that assesses attitudes towards mental illness and contains three subscales: Need for Treatment,
Worry, and Presence/Outcome of Illness. Bonabi et al. (2016) utilized the Need for Treatment subscale in a study of mental health service use in Switzerland and found that the measure predicted psychotherapy and psychiatric medication use over a 6-month period, even after controlling for sociodemographic characteristics, an objective measure of symptom severity
(Symptom Checklist-27), and self-reported lifetime mental health service use. However, although this study supported the predictive power of subjective evaluation of need, a significant methodological limitation is that Bonabi, et al. categorized psychotherapy and psychiatric medication use in a dichotomous manner (i.e., yes/no). As such, an individual who kept one treatment session and then declined further services was grouped alongside an individual who engaged in sustained and repeated treatment over a period of time. Future studies would benefit from capturing treatment in a more nuanced manner.
Mattering
The construct of mattering was introduced by Rosenberg and McCullough (1981) and defined as “the feeling that others depend on us, are interested in us, are concerned with our fate, or experience us as an ego-extension” (p. 165). Mattering consists of three components: awareness, importance, and reliance (Elliot et al., 2004; Rosenberg & McCullough, 1981).
Awareness is the degree to which people take note of one’s presence or acknowledge one’s TREATMENT ENGAGEMENT IN A PSYCHOLOGY CLINIC 13 existence. Importance is the feeling of being of concern to others, the degree to which other people invest in one’s welfare. And finally, reliance is the feeling that one is relied and depended on by other people. Elliot et al. (2004) empirically validated the construct of mattering by operationalizing Rosenberg and McCollough’s construct of mattering and creating the Mattering to Others Questionnaire (MTOQ).
Although the concept of mattering may appear similar to social support, research demonstrates that mattering is better understood as a distinct construct (Elliot et al., 2004;
Pernice et al., 2017). Whereas perceived social support is defined as the belief that others will provide for the specific needs that one experiences (Sherbourne & Stewart, 1991), mattering is much more of a general construct, encapsulating the perception of having people in one’s life who are continually interested in one’s welfare—an experience that moves beyond the provision of specific forms of support (Elliot et al., 2005). Research indicates that college students can have a variety of social supports (e.g., emotional—listening to problems; social—joining in a pleasant activity; informational—giving advice), yet not internally have the experience of mattering to others (Elliot et al., 2004).
Multiple factors have emerged as related to perceived mattering, such as mental health status, gender, race and ethnicity. Research has demonstrated a strong relation between mattering and mental health (Dixon & Kurpius, 2008; Elliot et al., 2005; Flett et al., 2012). For example, individuals who experience higher levels of mattering report less stress and depression (Cha,
2016; Dixon & Kurpius, 2008). Individuals who perceive themselves as strongly mattering to others have demonstrated lower risk of contemplating suicide (Elliot et al., 2005). Race and ethnicity appear to be predictors of perceived mattering, and individuals who identify as
Caucasian are more likely to experience higher levels of mattering compared to racial and ethnic TREATMENT ENGAGEMENT IN A PSYCHOLOGY CLINIC 14 minorities (Tucker et al., 2010). However, much is still unknown about mattering and its effects; for example, discrepant findings have emerged related to possible gender differences in mattering and its relation to symptoms of depression (Dixon & Kurpius, 2008; Taylor & Turner,
2001); although such discrepancies may be attributed to differing age groups and location of sample recruitment, they also suggest that mattering may operate differently in distinct subgroups.
Mattering appears amenable to change over time (Taylor & Turner, 2001). The mutable nature of mattering has led to the idea that interactions with a therapist may be able to facilitate the experience of mattering (Dixon & Kurpius, 2008; Rayle, 2006; Thomas, 2011). Although there is no empirical support to substantiate the idea that interactions with a therapist have direct effects on clients’ experience of mattering, longitudinal research conducted in the general population has demonstrated that perceived mattering can increase over time in adolescent
(Marshall & Tilton-Weaver, 2019), adult (Taylor & Turner, 2001), and older adult populations
(Francis et al., 2019). Additionally, although no research has identified if the interactions an individual has with a therapist directly influence clients’ sense of mattering, there is data suggesting that subjective mattering can be cultivated over the course of psychological treatment
(Pernice et al., 2017; Ridgway, 2001). As such, it may be that therapy promotes individuals’ ability to notice and internalize indicators of mattering to others outside of the therapy room.
Finally, some recent data suggest that mattering may serve as a conduit between social support and self-stigma related to having a mental illness (Pernice et al., 2017). Merely having people in life to give or receive assistance is not directly related to lower levels of internalized stigma.
Instead, mattering explains the relation between social support and self-stigma; having TREATMENT ENGAGEMENT IN A PSYCHOLOGY CLINIC 15 relationships presents the opportunity to experience one’s life as significant or valued, which is a protective factor against self-stigma (Pernice et al., 2017).
Psychological Treatment
Nationally representative data from the Healthy Minds Study (Eisenberg et al., 2011) indicated that only 36% of students who appeared to have a mental health problem (i.e., produced a positive screen for depression, generalized anxiety disorder, panic disorder, suicidal ideation, or self-injury) received any form of professional treatment within the previous 12 months. The disinclination to seek professional treatment is consistent with research showing that college students generally prefer to first seek informal help from friends and family when experiencing emotional distress (Drum et al., 2009; Eisenberg et al., 2011). In the Healthy Minds
Study, of those who did receive formal psychological treatment, 11% reported receiving medication only, 11% reported receiving psychotherapy only, and 14% reported receiving both
(Eisenberg et al., 2011). Results also indicated that for those college students who received counseling or therapy for their mental health issues, the most common service location was an on-campus provider. As research suggests that less than half of people in the general population who receive psychological treatment do so at or above levels considered minimally adequate according to evidence-based guidelines (i.e., at least eight sessions of therapy; Wang et al.,
2005), it is probable that many of the 36% of students who did receive treatment did not receive a sufficient dose to produce clinically significant, long-term change. Among the students who did not seek treatment, the most common reasons were: believing that stress was a normal aspect of college, doubting the severity of their problem, perceiving their problem would resolve itself without intervention, believing they did not have time to seek treatment, and preferring to handle problems on their own (Eisenberg et al., 2011). TREATMENT ENGAGEMENT IN A PSYCHOLOGY CLINIC 16
When attempting to identify individual difference correlates associated with help-seeking behavior, asking people about their future intent to engage in treatment if they perceived a need is intuitively appealing but contradicted by empirical findings. Specifically, a robust finding is that people are poor at estimating their likelihood of engaging in a future behavior. A meta- analysis of 47 experimental studies on behavioral intentions and behavior change revealed that a medium-to-large effect size for behavioral change intention engenders only a small-to-medium effect size in actual behavioral change (Webb & Sheeran, 2006). The meta-analysis also demonstrated that intentions to engage in a behavior are less predictive of actual behavior when there is potential for a social reaction to the behavior (e.g., the societal stigma associated with psychological help seeking). Thus, perceiving there could be a negative social reaction in response to engaging a behavior serves to reduce the influence of professed intention on actual behavior.
Additional factors that may influence psychological treatment engagement include wait times, attitudes, and expectations. There is conflicting evidence about whether longer wait times for an initial appointment significantly impact subsequent attendance (Al-Jabari et al., 2018;
Swift et al., 2012). Careful review of the divergent findings suggests that clinic differences in service availability and how staff communicate waitlist times to clients may be key to whether long wait times significantly impact session attendance. In regard to research on attitudes and expectations, it appears that people’s preconceived notions of what the treatment process will entail and beliefs about treatment success influence initial attitudes toward treatment (Swift et al., 2012); however, these expectations do not directly relate to whether a client shows up to an appointment they have already scheduled.
TREATMENT ENGAGEMENT IN A PSYCHOLOGY CLINIC 17
Premature Termination
Premature termination refers to clients who discontinue psychotherapy prior to completion (Swift et al., 2009). According to a meta-analysis of 125 published studies of psychological treatment dropout, the prevalence of premature termination falls between 30 and
60% (Wiertzbicki & Pekarik, 1993). The data suggest that training clinics have higher rates of premature termination compared to outpatient clinics within the same geographic region, perhaps due to a combination of inaccurate client expectations and trainee experience in directly addressing expectations (Callahan et al., 2009).
Investigation of factors associated with premature termination/treatment completion is complicated by varying operational definitions of what constitutes treatment completion across studies (Al-Jabari et al., 2018; Callahan et al., 2009). Some studies utilize more subjective measures of treatment completion, such as the client and therapist making a verbal agreement to terminate therapy. Others may utilize objective self-report symptom measures such as the OQ-
45, a progress monitoring tool (Al-Jabari et al., 2018; Callahan et al., 2014; Lambert et al.,
1996). Although each method of conceptualizing treatment completion and premature termination can be appropriate in many cases, both make less sense in the context of a university training clinic. Relying solely on progress monitoring tools such as the OQ-45 to categorize treatment completion for training clinic college student clients may not capture the variety of college students who benefit from treatment. For instance, using measures like the OQ-45 to classify treatment completion does not take into consideration individuals who begin with more modest symptom levels or those who frequently miss appointments and may receive a weakened dose of the therapeutic treatment (Leichsenring & Rabung, 2008). Similarly, an examination of cases of mutual termination versus unilateral termination at the end of treatment relies heavy on TREATMENT ENGAGEMENT IN A PSYCHOLOGY CLINIC 18 therapist appraisal of treatment completion and does not take into account the regularity of session attendance.
Due to the difficulties associated with defining treatment completion, it may be more useful to consider treatment engagement rather than completion; engagement is often operationalized as attendance, participation, or involvement (Holdsworth et al., 2014). For instance, attending a set number of sessions within the first few months of beginning therapy would be one way to conceptualize treatment engagement and is based on the dose-response model of psychotherapy (Erekson et al., 2015). According to the dose-response model, every session of psychotherapy is a “dose” which adds to the cumulative “response”—conceptualized as diminishment in overall psychological distress and improvement in intra- and interpersonal functioning. Yuan et al. (2019) operationalized treatment engagement as attending four or more therapy sessions; this operationalization was based on prior research on markers of treatment engagement (Spirito et al., 2002; Wood et al., 2001). Session timing has emerged as another important predictor of reduction in symptomology. Erekson et al., (2015) demonstrated that clients who attended weekly therapy sessions required four fewer sessions to make clinically significant improvements (operationalized by change scores on the OQ-45), compared to clients attending bi-weekly therapy sessions. Thus, it appears important to not only capture number of sessions but also session timing when measuring treatment engagement.
Current Study
The current study sought to investigate the individual and joint effects of help-seeking stigma, perceived symptom severity, and subjective mattering in predicting treatment engagement—defined as attending 4 or more therapy sessions within the first 2 months of treatment—at a university psychology clinic. Research in clinical and social psychology has TREATMENT ENGAGEMENT IN A PSYCHOLOGY CLINIC 19 often studied these factors in isolation from one another, making it difficult to understand the relative effect of each on psychological help-seeking. Another methodological limitation of prior investigations in this area is they have assessed the focal constructs of stigma, mattering, and symptomology at different stages of treatment rather than at the outset. These constructs are subject to change over time and psychotherapy—which is designed to evoke change in self- concept— is likely to influence individuals’ personal understanding and, in turn, their responses in these areas. Consequently, this study utilized self-report measures completed prior to the clinical sample’s intake appointment and before they began the process of reflecting on and describing to another person their internal world. Additionally, prior research on psychological help-seeking and treatment engagement has primarily relied on client self-report for determining treatment adherence; although a valuable source of information, self-report, particularly retrospective self-report, carries considerable uncertainty and reduces the reliability of obtained treatment adherence outcomes. To address this concern, this study utilized deidentified data extracted from a university psychology clinic’s electronic medical record system, which allowed for the objective quantification of treatment engagement. It also adopted a more robust definition of engagement and required multiple appointments to meet criteria. Finally, collecting data from a comparable non-clinical sample drawn from the same population of college students allowed for the clinical sample to be contextualized, permitting comparisons between the two groups on measures of help-seeking stigma, mattering, and perceived symptom severity.
Using this design, it was hypothesized that both samples would report similar levels of perceived mattering to others; however, help-seeking stigma was anticipated to be lower and perceived symptom severity was expected to be higher in the clinical sample. A negative relation between mattering to others and help-seeking stigma was anticipated in both samples. TREATMENT ENGAGEMENT IN A PSYCHOLOGY CLINIC 20
Additionally, it was hypothesized that self-stigma would be particularly prominent among individuals in the non-clinical sample with high perceived symptom severity. Finally, it was hypothesized that subjective mattering and perceived symptom severity would be predictive of greater treatment engagement and that help-seeking stigma would show a negative relation with treatment engagement.
Method
Participants
Participants included 246 undergraduate students recruited from a private Midwestern
University. Two separate samples, one clinical (n = 134) and one non-clinical (n = 112), were recruited to answer the primary questions. Inclusion criteria for both samples was being age 18 years or above. For the clinical sample, additional inclusion criteria was initiating psychological services at a university psychology training clinic. Exclusion criteria for the clinical sample included identifying as a graduate student. For the non-clinical sample there were no additional inclusion criteria; exclusion criteria was a history of past or present psychological or psychiatric treatment from either campus or community providers. Community treatment was defined as attending four or more therapy sessions over a period of 8 weeks and campus treatment was defined as attending four or more therapy sessions within an 8 week window, excluding campus breaks. Non-clinical participants were recruited through a School of Psychology participant pool and earned research participation course credit for their time. Clinical participants comprised an archival sample of clients seeking services from the host university’s School of Psychology training clinic during two time periods: August 1, 2018 through March 15, 2019 and August 1,
2019 through October 15, 2019. All clients who enter treatment at the clinic provide informed consent allowing their clinical information to be used for research purposes. The full sample was TREATMENT ENGAGEMENT IN A PSYCHOLOGY CLINIC 21 comprised of 170 female students, 75 male students, and 1 non-binary student, with a mean age of 19.79 years. The majority of participants (78.5%) identified as Caucasian, non-Hispanic.
Neither age, gender, nor ethnicity significantly varied across the two samples. Detailed participant demographic information is provided in Table 1.
Measures
Demographics and Help-Seeking Behavior Questionnaire (DHSBQ). The DHSBQ was completed by the nonclinical sample only. It was developed for this study to collect demographic information, including age, year in school, identified gender, ethnicity, and involvement with mental health services. Participants were coded as having a history of involvement with mental health services and excluded from all analyses if they responded “yes” to the following item: “Have you ever attended 4 or more sessions within a 2-month period with a mental health service provider (e.g., counselor, therapist, psychologist, psychiatrist)?” Non- clinical participants were also excluded from analyses if they indicated any current use or past year use (even if less than 4 sessions) of psychological services at the on-campus training clinic to ensure independence of the two samples. See Appendix A.
Perceived Likelihood of Attending Therapy Sessions Questionnaire (PLATSQ). The
PLATSQ was used with the clinical sample only. The PLATSQ is a single-item self-report measure created for this study designed to capture a new client’s anticipated engagement in therapy. Using a 5-point Likert-type response scale, ranging from 1 = extremely unlikely to 5 = extremely likely, participants indicated their likelihood of attending each therapy session as recommended to them at the university psychology training clinic. See Appendix B.
Perceived Likelihood of Attending Therapy Non-Clinical Questionnaire (PLATNQ).
The PLATNQ was used with the non-clinical sample only. The PLATNQ is a two-item self- TREATMENT ENGAGEMENT IN A PSYCHOLOGY CLINIC 22 report measure created for this study to capture hypothetical anticipated engagement in psychological services in the event of emergent psychological symptoms. Using a 5-point Likert- type response scale, ranging from 1 = extremely unlikely to 5 = extremely likely, participants indicated their perceived likelihood of seeking out psychological services. Participants also selected from a list all places they would consider seeking psychological services (e.g., psychology training clinic only, counseling center and psychology training clinic, community provider, etc.); participants were able to select multiple locations. See Appendix C.
Self-Stigma of Seeking Help Scale (SSOSH). The SSOSH (Vogel et al., 2006) was completed by both samples. The SSOSH measured self-stigma related to seeking psychological help. The SSOSH consists of 10-items, each of which is rated using a 5-point Likert-type response scale, ranging from 1 = strongly disagree to 5 = strongly agree. Sample items include
“Seeking psychological help would make me feel less intelligent” and “I would feel worse about myself if I could not solve my own problems.” Half of the items are reverse-scored. All 10 items are summed to create a total score, which can range from 10 to 50. Higher total scores indicate that a person experiences greater levels of self-stigma related to seeking therapy and perceives help-seeking as a greater threat to their self-esteem. Due to a data collection error, 61 out of 112 non-clinical participants completed only 9 of the 10 SSOSH scale items; the missing item was
“My self-esteem would increase if I talked to a therapist” (reverse-scored). However, the 9-item and 10-item versions of the SSOSH demonstrated comparable internal consistency. Within the non-clinical sample, both the 9-item and 10-item versions of the SSOSH demonstrated good internal consistency, α = .88 and .83, respectively, with the 9-item version being slightly stronger. To determine the acceptability of using the 9-item version only, its performance was also assessed in the clinical sample. Within the clinical sample, the 9-item and 10-item versions TREATMENT ENGAGEMENT IN A PSYCHOLOGY CLINIC 23 performed comparably: α = .79, and α = .80, respectively. Across all participants (combined samples), the 9-item SSOSH demonstrated good internal consistency, α = .84. Across participants who completed all 10 items, the 10-item SSOSH demonstrated good internal consistency, α = .81. Although both versions showed good reliability, to maintain consistency with past research, the standard 10-item version was used for analyses that included only the clinical sample. For analyses which utilized data from the non-clinical sample or both samples, the 9-item SSOSH was used in order to retain all participants. This approach was selected rather than replacing the missing data. See Appendix D.
Mattering to Others Questionnaire (MTOQ). The MTOQ (Elliot et al., 2004) is a 24- item self-report questionnaire that was used to assess perceived mattering. The three subscales are: 1) Awareness which contains 8 items; a sample item is “Most people do not seem to notice when I come or when I go” (reverse-scored); 2) Importance which contains 10 items; a sample item is “My successes are a source of pride to people in my life;” and 3) Reliance which contains
6 items; a sample item is “Other people trust me with things that are important to them.”
Participants rated each item on a 5-point Likert-type scale ranging from 1 = strongly disagree to
5 = strongly agree. Half of the items were reverse-scored. All 24 items are summed to create a total score, which can range from 24 to 120. Higher scores indicate a greater degree of perceived mattering to other people. The MTOQ performed well. The total score MTOQ demonstrated excellent internal consistency within the full sample, α = .90, within the clinical sample, α = .90, and within the non-clinical sample, α = .90. Internal consistencies for the subscales (awareness, importance, reliance) had good reliability in the full study sample (α = .85, .83, and .90, respectively), in the clinical sample (α = .86, .83, and .90, respectively), and in the non-clinical sample (α = .83, .80, and .91, respectively). See Appendix E. TREATMENT ENGAGEMENT IN A PSYCHOLOGY CLINIC 24
Self-Appraisal of Illness Questionnaire-Revised (SAIQ-R). A revised version of the
SAIQ (Marks et al., 2000) was used to assess personal attitudes toward mental illness. The SAIQ is a 17-item self-report measure that contains three subscales: Need for Treatment, Worry, and
Presence/Outcome of Illness. Only the Need for Treatment subscale, which contains 6 items, was used in this study. Participants rated items on a 4-point Likert-type scale. Four items (e.g., “I have symptoms of mental illness”) used the anchors 1 = strongly agree to 4 = strongly disagree.
A single item (“Do you believe you need mental health treatment for your current problems?”) used the anchors 1 = definitely to 4 = definitely not. A single item (“If you did not receive mental health treatment, how do you think you would be doing?”) used the anchors 1 = doing very poorly to 4 = doing very well. Items were revised to make them relevant to both the clinical and non-clinical participants by changing “your condition” to “your problems.” In this study, all 6 items were reverse-scored and summed to capture perceived symptom severity, with higher scores indicating greater perceived symptom severity. Total Need for Treatment scale scores can range from 6 to 24. The Need for Treatment scale demonstrated adequate internal reliability within the full sample (α = .88), clinical sample (α = .79), and non-clinical sample (α = .83). A median split on the Need for Treatment total score was used to create two levels: low perceived symptom severity and high perceived symptom severity. The median split was calculated separately for the clinical and non-clinical samples; this was done to ensure that there were roughly equal numbers of each subsample within the two levels (low/high perceived symptom severity). The median Need for Treatment score was 17 for the full sample, 19 for the clinical sample, and 14 for the non-clinical sample. See Appendix F.
Outcome Questionnaire 45 (OQ-45; Lambert et al., 1996). The OQ-45 was used to assess objective symptom levels. The OQ-45 is a general measure of client distress and used for TREATMENT ENGAGEMENT IN A PSYCHOLOGY CLINIC 25 assessing therapy progress and outcomes. The OQ-45 consists of 45 self-report items rated using a 5-point Likert-type scale ranging from 0 = never to 4 = almost always to describe current experience. All items are summed to create a total score which can range from 0 to 180. A total score of 63 or greater is indicative of clinically significant symptoms. The OQ-45 contains 3 subscales: Symptom Distress, Interpersonal Relations, and Social Role. Scores on the Symptom
Distress subscale range from 0 to 100, with higher scores indicate greater distress; a sample item is “I feel no interest in things.” Scores on the Interpersonal Relations subscale range from 0 to
44, and higher scores demonstrate greater interpersonal difficulties; a sample item is “I have trouble getting along with friends and close acquaintances.” Scores on the Social Role subscale range from 0 to 36, and higher scores represent greater difficulties in the social roles of worker, homemaker, and/or student; a sample item is “I am not working/studying as well as I used to.”
The OQ-45 total score was used for this study. The OQ-45 total score demonstrated excellent internal consistency in the full sample (α = .94), in the clinical sample (α = .91), and in the non- clinical sample (α = .94). Internal consistencies for the subscales (symptom distress, interpersonal relations, social role) showed varying reliability in the full study sample (α = .93,
.78, and .64, respectively), in the clinical sample (α = .88, .75, and .58, respectively), and in the non-clinical sample (α = .93, .82, and .67, respectively). See Appendix G.
Treatment Engagement Capture Form (TECF). The TECF was created for this study to capture each clinical sample participant’s engagement in treatment. Specifically, the following information was extracted from clients’ clinical charts: attendance at scheduled intake appointment (yes/no), date of first scheduled session, date of first scheduled session + 60 days
(excluding days when university classes are not in session) to establish treatment window, number of sessions scheduled in treatment window, number of sessions attended in treatment TREATMENT ENGAGEMENT IN A PSYCHOLOGY CLINIC 26 window, whether the client attended at least four sessions in the treatment window (yes/no), and whether the client attended any additional sessions after treatment window (e.g., the first 8 weeks of treatment). All items were used to determine the final item “Did the client attend at least four sessions within the first 8 weeks of treatment (including the first scheduled session)?”
Participants who were coded “no” on the final item were categorized as treatment nonengagers
(no = 0). Participants who were coded “yes” were categorized as treatment engagers (yes = 1).
See Appendix H.
Shared Procedure
Prior to the onset of data collection and data extraction, approval was obtained from the university’s institutional review board (IRB; see Appendix I).
Clinical Sample Procedure
The clinical sample was obtained using archival data from the training clinic. The data catchment window was all clients who had a scheduled intake appointment from August 1, 2018 through March 15, 2019 and August 1, 2019 through October 15, 2019. In keeping with routine clinic procedures, each client completed a clinic demographic questionnaire and a number of assessment measures. This study used the PLATSQ, SSOSH, MTOQ, SAIQ-R and OQ-45.
Clients were emailed clinic paperwork, including the PLATSQ, SSOSH, MTOQ, SAIQ-R, after scheduling their intake appointment and asked to complete it prior to their appointment. At the intake appointment, clients completed the OQ-45. For clients who decided to enter treatment, attendance at each subsequently scheduled individual therapy appointment was recorded by the treating therapist. All intake data and attendance information were entered into and managed by an electronic medical record system, Titanium™. For each client who entered treatment during TREATMENT ENGAGEMENT IN A PSYCHOLOGY CLINIC 27 the catchment period, demographic information, the PLATSQ, SSOSH, MTOQ, SAIQ-R, baseline OQ-45, and treatment attendance were extracted and deidentified
Non-Clinical Sample Procedure
Non-clinical participants were recruited through the School of Psychology research participant pool and received course research credit for their participation. All responses were anonymous. All students who met inclusion criteria (n = 194) were provided the opportunity to participate in the study and earn the research credit; however, only data from the subset who did not report exclusion criteria (n = 112) were used. Data collection occurred using two formats.
Between November 2019 and March 6, 2020, data collection was conducted in-person within the psychology building. Upon arriving at the data collection location, participants underwent an informed consent process, after which they were provided with a URL to access an online
Qualtrics survey containing the study materials. Participants completed questionnaires in the following order: DHSBQ, PLATNQ, SSOSH, MTOQ, SAIQ-R, and OQ-45; a total of n = 114 completed this procedures. In March 2020, the COVID-19 pandemic emerged and data collection shifted to a fully remote format. The Qualtrics survey link was distributed through participant management software (Sona) for the remaining data collection (n = 80).
Results
Preliminary Analyses
Prior to hypothesis testing, all cases which did not meet inclusion and exclusion criteria were removed from the data set, this resulted in a potential sample of N = 247. Next, all continuous variables were visually and statistically examined for normalcy. Univariate outlier analyses were conducted for continuous variables and revealed 7 outlier data points across 5 unique participants; outliers were defined as values more than 3 standard deviations from the TREATMENT ENGAGEMENT IN A PSYCHOLOGY CLINIC 28 mean (Osborne & Overbay, 2004). The 7 data points were each recoded to the value associated with 3 standard deviations from the mean (Tukey & McLaughlin, 1963). Multivariate outlier analyses, including calculations of Mahalanobis distance, Cook’s distance, and centered leverage values, were conducted for continuous variables (Osborne & Overbay, 2004). Results revealed one remaining case with extreme values. The case included three of the outlier data points that had previously been recoded during univariate outlier analyses; the participant was excluded from final analyses. The final data set included 246 participants: 134 clinical and 112 non- clinical. 11 unique participants within the clinical subgroup had data missing completely at random; 6 participants were not administered the OQ-45 at their intake appointment and 5 participants did not complete the PLATSQ, SSOSH, MTOQ, and SAIQ-R prior to their intake appointment. These participants were retained in the dataset and included in analyses for which they had sufficient data. The two subsamples within the non-clinical group, participants who completed the study in-person and participants who completed the study in a fully remote format, were compared on demographic and study variables. This was done to determine whether the emergence of the COVID-19 pandemic was associated with changes in who participated in the study or how participants answered study variables (e.g., symptom level scores on the OQ-45). Results demonstrated that the in-person and fully remote subsamples did not significantly differ on any variable. See Appendix J.
Descriptive Analyses
See Table 2 for descriptive statistics of each study variable by subsample (clinical/non-clinical).
Non-Clinical Sample Likelihood to Use Mental Health Services. The likelihood of seeking treatment in the event of emergent mental health symptoms was assessed in the nonclinical sample. The majority of participants (54.5%) rated themselves as either likely (n = TREATMENT ENGAGEMENT IN A PSYCHOLOGY CLINIC 29
51) or extremely likely (n = 10) on the 5-point Likert-type scale to seek mental health services.
By comparison, 36.6% of participants rated themselves as either unlikely (n = 39) or extremely unlikely (n = 2) to seek mental health services. A relatively small proportion of participants
(8.9%) were neutral, rating themselves as neither likely nor unlikely (n = 10) to seek mental health services. Willingness to utilize various types of mental health services was assessed in the non-clinical sample; participants could select more than one option. Of the 61 participants who indicated they were likely or extremely likely to seek help, 80.3% were willing to seek services from the on-campus counseling center affiliated with student health services, which was the most popular option. See Table 3 for detailed information.
Treatment within the Clinical Sample. Of the 134 undergraduate clients who scheduled intake appointments and completed any of the study questionnaires during the data catchment window, 97.8% (n = 131) attended their intake appointment, 91.8% (n = 123) scheduled at least one individual therapy session, and 88.8% (n = 119) attended at least one individual therapy session. In the subsample (n = 123) who scheduled at least one therapy session, an average of
7.85 sessions were scheduled and 6.42 sessions were attended. Overall, 76.9 % (n =103) clients were classified as treatment engagers and attended at least four sessions within the first 8 weeks of treatment. Additionally, 67.9% (n = 91) attended at least one additional session after the first 8 weeks of treatment within the full catchment window.
Full Sample Hypotheses
Full Sample Hypotheses. It was hypothesized that individuals in the clinical sample, compared to those in the non-clinical sample, would: 1) report significantly lower levels of help- seeking stigma; 2) report significantly higher levels of perceived symptom severity and 3) report no significant difference in perceived mattering. All three hypotheses were tested using a single TREATMENT ENGAGEMENT IN A PSYCHOLOGY CLINIC 30 one way multivariate analysis of variance (MANOVA). The grouping variable was clinical sample and had two levels: clinical and non-clinical. The dependent variables were the Help- seeking Stigma total score, the Self-Appraisal of Illness Questionnaire-Revised Need for
Treatment subscale score, and the Mattering to Others total score. The level of significance was set at p < .05. This first two hypotheses were supported; the results of the MANOVA indicated a significant difference between the two samples for help-seeking stigma, F(1, 239) = 9.76, p =
.002, and perceived symptom severity, F(1, 239) = 156.76, p < .001. Participants in the clinical sample reported significantly lower help-seeking stigma (M = 19.78) and higher perceived symptom severity (M = 18.72) compared to individuals in the non-clinical sample (M = 22.12 and 13.79, respectively). The third hypothesis was not supported by the data; the MANOVA revealed a significant relation between sample and perceived mattering, F(1, 239) = 10.61, p = .001. Specifically, participants in the clinical sample reported significantly less perceived mattering (M = 86.44) than individuals in the non-clinical sample (M = 91.54). See Table 2.
It was also hypothesized there would be a significant interaction between perceived symptom severity and sample status on help-seeking stigma; specifically, individuals in the non- clinical sample with high levels of perceived symptom severity would show higher levels of help-seeking stigma compared to individuals in the clinical sample with high levels of perceived symptom severity. The hypothesis was tested using a two way between-subjects analysis of variance (ANOVA). The independent variables were sample (clinical and non-clinical) and perceived symptom severity (low perceived symptom severity and high perceived symptom severity based on median split of Need for Treatment scale). The dependent variable was total help-seeking stigma score. The level of significance was set at p < .05. Results of the ANOVA supported the hypothesis; there was a significant interaction between sample and perceived TREATMENT ENGAGEMENT IN A PSYCHOLOGY CLINIC 31 symptom severity, F(1, 237) = 3.76, p = .05. Non-clinical participants who reported high symptom severity demonstrated greater help-seeking stigma (M = 22.22) compared to clinical participants who reported high symptom severity (M = 18.63).
Primary Clinical Sample Hypotheses
It was hypothesized there would be a negative relation between subjective mattering to others and perceived help-seeking stigma among clinical sample participants. The hypothesis was tested using a bivariate correlation and was not supported, r(127) = -.07, p = .44.
It was hypothesized that perceived symptom severity would predict treatment engagement and individuals who reported higher perceived symptom severity at baseline would show increased odds of treatment engagement (defined as attending at least 4 therapy sessions in the first 8 weeks of treatment while university classes were in session). The hypothesis was tested using logistic regression as the outcome variable, treatment engagement, was dichotomous
(0 = no engagement/ 1= engaged). Results indicated the hypothesis was not supported. Although a significant relation between perceived symptom severity and treatment engagement emerged, it was opposite in direction to predictions, β = -.17, p < .05, OR = .84. The odds of engaging in treatment was 16% lower for clients with high perceived symptom severity compared to low perceived symptom severity.
Primary Non-Clinical Sample Hypothesis (NSH)
It was hypothesized there would be a negative relation between subjective mattering to others and perceived help-seeking stigma among non-clinical participants. The hypothesis was supported as results indicated a significant, moderate, negative correlation between mattering and help-seeking stigma, r(110) = -.54, p < .001. Non-clinical participants who reported greater subjective mattering to others were less likely to report perceived help-seeking stigma. TREATMENT ENGAGEMENT IN A PSYCHOLOGY CLINIC 32
Exploratory Analyses
A prediction model using logistic regression was built in the clinical sample to examine the relations between demographic information, stigma related to help seeking, subjective mattering to others, perceived symptom severity, objective symptom severity, and likelihood to attend therapy and to identify which factors were uniquely and significantly predictive of treatment engagement.
The following relations were predicted:
1: Help-seeking stigma would show a significant negative relation and decreased odds of treatment engagement in the multivariate model.
2: Subjective mattering to others would show a significant positive relation and increased odds of treatment engagement in the multivariate model.
3: Perceived symptom severity would show a significant positive relation and increased odds of treatment engagement in the multivariate model.
4: Objective symptom severity would be unrelated with treatment engagement in the multivariate model.
5: Perceived likelihood of attending therapy sessions at the outset of treatment would be unrelated with treatment engagement in the multivariate model.
Prior to building the model, all potential demographic predictors were assessed on a univariate level for model inclusion; significance was set at a relaxed rejection level of p < .2 to retain all potentially important control variables (Cohen & Swerdlik, 2010). As seen in Table 4, no demographic factor showed any relation with outcome and none were retained. Univariate tests were run with all theoretical predictors (see Table 5). Next, all theoretical predictors were entered into the model simultaneously and examined for their relation to outcome. Predictors TREATMENT ENGAGEMENT IN A PSYCHOLOGY CLINIC 33 were sequentially removed based on their relation to outcome, and the model was retested until only significant predictors accounting for unique variance in treatment engagement remained
(see Table 6). The final model for the clinical sample included only one variable, perceived mattering to others, β = .05, p = .01, OR = 1.04. Prediction 2 was supported; clinical participants who reported higher perceived mattering were more likely to attend at least four sessions of therapy within the first 2 months of treatment. Predictions 4 and 5 were also supported. As expected, objective symptom severity (total OQ-45 score) did not show a significant relation with treatment engagement in the multivariate model, β = .01, p = .75. Consistent with prediction
5, perceived likelihood of attending therapy sessions at the outset of treatment was unrelated to treatment engagement in the reduced multivariate model, β = -.40, p = .28.
Predictions 1 and 3 were not supported. Contrary to hypothesis 1, help-seeking stigma was not related to decreased odds of treatment engagement in the multivariate model, β = -.06, p
= .20. And, lastly, perceived symptom severity showed a significant relation to outcome only in the initial univariate model; this relation, however, was in the opposite direction of what had been hypothesized, β = -.17, and indicated lower perceived symptom severity was associated with higher engagement. However, the result did not obtain on the multivariate level.
Specifically, when perceived symptom severity and perceived mattering were the only two variables remaining in the model, perceived symptom severity dropped out of significance, β = -
.14, p = .12.
Discussion
The current study investigated the independent and joint predictive power of help-seeking stigma, perceived symptom severity, and subjective mattering for treatment engagement and psychological help-seeking. This study advances our knowledge in this area as prior research has TREATMENT ENGAGEMENT IN A PSYCHOLOGY CLINIC 34 primarily focused on each psychological construct in isolation. Strengths of the study include the use of both a clinical (clients at a university training clinic) and a non-clinical comparison
(undergraduate students) sample and a robust definition of treatment engagement—attending 4 or more therapy sessions in the first 2 months of treatment. Knowledge about factors associated with treatment engagement is an important area of study as a recurrent finding is many people do not remain in treatment long enough to receive a sufficient dose to produce clinically significant, long-term change (Gibbons et al., 2011; Wang et al., 2005).
Clinical Sample Treatment Engagement
Clients who contacted the clinic were likely to engage in treatment. Most clients who contacted the clinic and completed initial paperwork made some forward movement; only 3 did not attend their initial intake appointment and an additional 12 clients did not schedule and/or attend any sessions with their assigned therapist. Review of these clients’ objective distress (i.e.,
OQ-45 scores) indicated all three who did not keep their intake appointment showed subclinical distress, as did four (33%) of those who fell away after intake. The remaining eight who were lost after intake showed clinically significant distress ranging from mild (total score = 73) to severe (total score = 103).
Most clients (89%) attended at least one session of treatment. In the full sample, clients kept 82% of sessions they scheduled with their graduate student therapists. A supermajority of clients (77%) demonstrated clear engagement, defined as attending at least four sessions within the first 60 days of treatment. Treatment engagement appears greater in this study considering that the Center for Collegiate Mental Health 2015 Annual Report showed the average number of total counseling sessions attended in a year was 4.71 (including intake appointment) and the modal number of sessions for college students was one. Treatment engagement might be greater TREATMENT ENGAGEMENT IN A PSYCHOLOGY CLINIC 35 in this study due to a number of factors such as university-wide organizational support for mental health care. For example, at the Jesuit undergraduate institution from which participants were drawn, mental health care is promoted at orientation and on class syllabi and Cura Personalis,
“care for the entire person,” is a core university wide value. Additional factors contributing to high treatment engagement in this sample may include the relatively small size of the undergraduate student body and/or lack of a waitlist for on-campus mental health services.
Consistent with predictions, client report of anticipated engagement at the onset of treatment was unrelated to actual engagement. Participants overwhelmingly anticipated attending each recommended therapy session with 87% rating their attendance as either extremely likely
(49.3%) or likely (38.1%). As expected, anticipated likelihood of attending therapy sessions— although accurate—was not significantly related to treatment engagement, a result that can be attributed to highly restricted range as few clients expressed reservations about moving forward with treatment and most clients engaged with treatment. However, greater than one-fifth of participants who rated themselves as extremely likely or likely to attend each recommended therapy session (n = 26) ultimately did not engage in treatment, further illustrating that people are poor at predicting their future behavior.
Comparison Sample Treatment Engagement
The comparison sample was comprised of undergraduates who reported no history of meaningful mental health treatment. Notably, a total of 194 students were screened to identify the required 112 non-treatment seekers required by power analyses. Thus, approximately 40% of undergraduate students recruited from a participant pool reported either recent therapeutic support from the on-campus psychology training clinic and/or a history of engaging in psychological treatment and were excluded. Additionally, within the final 112 students in the TREATMENT ENGAGEMENT IN A PSYCHOLOGY CLINIC 36 comparison sample, 34% (n = 38) reported some history of seeking services from a “mental health professional,” but not consistently enough or for a sufficient period of time to be classified as having engaged in psychological treatment. Additionally, a meaningful proportion of the comparison sample reported significant psychological distress as 40 participants (36%) produced a clinically significant total score of 63 or greater on the OQ-45; less than half (n = 16) of these individuals reported a history of seeking services from a mental health professional. Overall, the rate of mental health utilization within this study appears similar to other samples (Eisenberg et al., 2007), which found that only 36% of students who screen positive for depression sought services in the last year compared to 40% of significantly distressed students who previously sought (limited) treatment in the current study. Eisenberg et al. defined mental health service utilization as taking any psychotropic medication and/or attending a minimum of one session of psychotherapy.
Over half of the comparison sample (n = 61) reported they were likely or extremely likely to obtain psychological treatment in the event of emergent psychological symptoms. Counseling services at the on-campus counseling clinic was the most selected location for possible psychological treatment across all participants (78.6%), followed by therapy at the on-campus psychology training clinic (37.5%), on-campus psychiatric (medication, not counseling) services
(19.6%), and off-campus community mental health services (13.4%).
Symptom Severity Measures
It was hypothesized that individuals in the clinical sample would report significantly higher levels of perceived symptom severity, that is, higher perceived need for treatment. As expected, participants in the clinical sample reported higher perceived need for treatment and subjective symptom severity, than participants in the comparison sample. Additionally, TREATMENT ENGAGEMENT IN A PSYCHOLOGY CLINIC 37 participants in the clinical sample produced higher scores on the objective symptom measure compared to participants in the comparison sample. In both samples, the Outcome Questionnaire
45 and Self-Appraisal of Illness Questionnaire-Revised were moderately and positively correlated, providing evidence that there is a relation between objective symptom levels and perceived symptom severity but the two are distinct factors.
The predictive utility of objective and subjective symptom severity for treatment engagement was investigated in the clinical sample. Based on prior findings (Bonabi et al., 2016;
Sirey et al., 2001), it was predicted that perceived symptom severity would be a more important predictor of treatment engagement than objective symptom levels. Although this prediction was supported, the pattern of results that emerged was unexpected. Specifically, although, as expected, objective symptom levels were unrelated to treatment engagement and a significant relation between baseline perceived symptom severity significantly and treatment engagement emerged, the relation was opposite in direction to predictions. Perceived symptom severity demonstrated an unexpected inverse relation to treatment engagement in the clinical sample: clinical participants with higher perceived symptom severity were significantly less likely to engage in treatment. This study finding is at odds with the work of Sirey et al. (2001) and Bonabi et al. (2016); in both, participants who reported higher perceived symptom severity were more likely to carry out their recommended treatment regimen or use mental health services. One possible explanation for this discrepancy is the use of different methodology; Sirey et al. relied on the self-reported compliance of adult outpatients prescribed an antidepressant medication and
Bonabi et al. relied on self-reported attendance of any (i.e., yes/no) psychotherapy; in contrast, this study utilized behavioral data of actual session attendance. Another possible explanation is that individuals with high perceived need for treatment are likely to be experiencing more severe TREATMENT ENGAGEMENT IN A PSYCHOLOGY CLINIC 38 psychiatric conditions. It is possible that they perceived the initial treatment sessions as less effective than those experiencing milder issues and stopped attending. Additionally, research suggests that individuals with more severe psychiatric conditions are more likely to report negative experiences with treatment providers (Andrade et al., 2014). It is notable that overall the clinical participants in the current study reported marked perceived symptom severity; both the modal and median scores on the Need for Treatment scale of the Self-Appraisal of Illness
Questionnaire-Revised were 19 (out of 24 possible).
Although lower perceived need for treatment was related to treatment engagement when examined in isolation, it was not when considered in the context of other factors. When analyzing the joint effects of mattering, stigma and need for treatment on treatment engagement, perceived symptom severity was no longer predictive; in other words, clinical participants’ perceived need for treatment did not account for unique variance in predicting treatment engagement when perceived mattering to others was also included in the model. This may be due to what appears to be a social component related to insight of symptom severity (Lysaker et al.,
2019). The three facets of perceived mattering to other people—awareness, importance, reliance—captured the predictive power of perceived need for treatment on engagement. Perhaps the strong social ties which allow for people to experience mattering also allow people to develop accurate representations of their mental health issues. Said another way, relationships appear to impact both perceived mattering to others and perceived need for treatment: relationships can provide people with the experience of being noticed, important, and relied upon
(e.g., having a friend comment on how one is staying home, isolating, and being irritable). The experience of mattering to others can inform people that they could benefit from mental health treatment (e.g., being told by a close friend “I’m worried about you.”). TREATMENT ENGAGEMENT IN A PSYCHOLOGY CLINIC 39
Help Seeking-Stigma
It was hypothesized that individuals in the clinical sample would report significantly lower levels of help-seeking stigma compared to individuals in the non-clinical sample. As expected, the clinical sample reported lower perceived stigma of seeking psychological help than those in the non-clinical sample. This finding is consistent with previous work by Vogel et al.
(2006), which demonstrated that among college students’ lower levels of self-stigma predicted increased likelihood of seeking psychological services. It was also hypothesized that non-clinical participants who reported high perceived symptom severity would demonstrate the highest levels of help-seeking stigma of all participants in this study. Support was found for this hypothesis; non-clinical participants with high perceived symptom severity reported greater help-seeking stigma compared to clinical participants with high perceived symptom severity. This too was consistent with past findings (Livingston & Boyd, 2010; Lysaker et al., 2013) and suggests that help-seeking stigma is a primary barrier to treatment. This finding underscores the need for educational campaigns to combat help-seeking stigma so that individuals who identify themselves as in need of psychological treatment are empowered to seek out services.
Help-seeking stigma was tested as a predictor of treatment engagement within the clinical sample. It was expected that help-seeking stigma would decrease the odds of clients attending 4 sessions within the first 2 months of treatment. Unexpectedly, however, help-seeking stigma was not related to treatment engagement in the clinical sample. This finding cannot be explained by range restriction or floor/ceiling effects, because scores on the psychological help-seeking stigma variable produced a normal and relatively broad distribution within the clinical sample. Rather, it appears that psychological help-seeking stigma functions differently within groups of people who have already entered into psychological treatment. Previous research by Vogel et al. (2006) TREATMENT ENGAGEMENT IN A PSYCHOLOGY CLINIC 40 demonstrated that higher levels of self-stigma are negatively related to help-seeking attitudes, help-seeking intent, and historical self-reported mental health help-seeking behavior (any/none) over a 12-month period; the current study adds to the literature by suggesting that once a college student enters into on-campus treatment, help-seeking stigma no longer plays a significant role in whether or not the person engages in the treatment. For those who experience help-seeking stigma, perhaps the action of initiating and participating in psychological treatment leads to cognitive dissonance, thus encouraging over time a shift in stigmatizing beliefs about psychological help-seeking. Future studies may consider assessing psychological help-seeking stigma at regular intervals throughout the treatment process to examine this hypothesis. Or, it may be that help-seeking stigma remains stable over the course of treatment, but other factors are realized to be more critical to the individual and their decision to remain in treatment (e.g., relationships to other people; perceived mattering to others).
Perceived Mattering
It was hypothesized that clinical and non-clinical participants would not differ in terms of perceived mattering to other people. This was not supported. Non-clinical participants reported significantly higher perceived mattering (M = 91.54) compared to clinical participants (M =
86.44). This finding may be partially explained by the work of Dixon & Kurpius (2008), who found participants who reported increased mattering also reported fewer symptoms of depression and decreased stress; thus, the non-clinical sample may experience higher rates of mattering related to their, on average, lower objective symptom levels. There appears to be support for this hypothesis. Non-clinical participants with high objective symptom levels (i.e., OQ-45 scores 63 or greater) did not demonstrate significantly different levels of mattering (M = 84.05) than clinical participants with high objective symptom levels (M = 84.79), p = .61. TREATMENT ENGAGEMENT IN A PSYCHOLOGY CLINIC 41
The two samples were independently examined to better understand the relation between perceived mattering and help-seeking stigma. It was expected that, within both samples, mattering would be inversely related to help-seeking stigma. This was supported only in the non- clinical sample where the relation between perceived mattering and help-seeking stigma was significant and in the expected direction. This result is consistent with the findings of Atkey
(2015), who examined a sample of Canadian high school students and found a significant negative relation between mattering to others and self-stigma of psychological help-seeking.
Within the clinical sample, no significant association emerged. Once again, the finding cannot be explained by range restriction or ceiling/floor effects as both perceived mattering and help-seeking stigma showed normal and relatively broad distributions. Rather, these results suggest that, among college students, help-seeking stigma may play an important role in self- concept among non-clinical samples but becomes deactivated once individuals have made the decision to enter treatment. However, prior findings have been inconsistent, and much remains unknown about the role of stigma in self-concept and mattering. For example, Shannon, et al.
(2020) studied a sample of Canadian undergraduate students and found no relation between mattering to others and internalized help-seeking stigma; similar to the finding within the present study’s clinical sample, the correlation was nominally negative but nonsignificant. However,
Pernice et al. (2017) found in a sample of adult outpatients with severe mental illness that feelings of not mattering were associated with self-stigma related to having a psychiatric condition. Viewed as a whole, both current and prior results suggest that all self-stigma is not equivalent, and stigma associated with psychological help-seeking among generally high functioning college students may operate differently than the stigma associated with having a diagnosed mental illness in a community sample. It bears noting that the presence of internalized TREATMENT ENGAGEMENT IN A PSYCHOLOGY CLINIC 42 stigma related to having a psychiatric condition was not assessed in the current sample and may have produced different results. However, in sum, it seems the relations between perceived mattering and various type of internalized stigma are quite complex, and can vary by characteristics of the sample, including age, severity of psychiatric issues, and geographic region.
Finally, all theoretical constructs—mattering, self-stigma, objective and perceived symptom severity— were jointly examined in the clinical sample using logistic regression to identify which, if any, showed unique associations with treatment engagement. Although, as anticipated, mattering to others significantly increased the odds of engaging in treatment within the university psychology clinic, it was the only construct to do so. As noted, although perceived symptom severity predicted treatment engagement on a univariate level, it showed no association after accounting for mattering. This finding suggests there is a social component to people’s awareness of their psychiatric symptoms, at least some of which is captured by the experience of mattering. Similar ideas about have been hypothesized by Lysaker et al. (2019). Lysaker argues that insight involves metacognition which is both automatic (i.e., beliefs that come from within the person) and intersubjective (i.e., beliefs that come from relating to others). Clinical participants’ perceived symptom severity may be accounted for by their experience of mattering to others, experiencing others as noticing them (“People are usually aware of my presence;” item
4), deeming them important (“There are people in my life who care enough about me to criticize me when I need it;” item 15), and relying on them (“When people need help, they come to me;” item 22). Thus, a person’s ability to perceive their own psychiatric symptoms and believe they need treatment may be a function of any of these three components of mattering, along with the belief that seeking treatment is highly important in order to maintain current relationships
(Atkey, 2015). There seems to be support for this hypothesis. Both the importance (β = 0.14, p = TREATMENT ENGAGEMENT IN A PSYCHOLOGY CLINIC 43
.02) and reliance (β = 0.11, p = .02) subscales of mattering were significantly related to treatment engagement; clinical participants who viewed themselves as important to and relied on by others were more likely engage in psychotherapy. The awareness subscale was not significantly related to treatment engagement, β = 0.07, p = .16. When all three subscales were entered into the model concurrently, only the reliance subscale continued to significantly predict variance in treatment engagement, β = 0.10, p = .045. The importance subscale dropped out of significance, β = 0.14, p
= .06. This suggests that being relied on by other people explains the most variance in treatment engagement. This result is consistent with the long standing finding that being responsible for someone/something has beneficial effects (Rodin & Langer, 1977). To put it another way, people who are clinically depressed and get a dog may be more likely to engage in behavioral activation because they now have a pet that is relying on them. In effect, taking a walk transitions from being a volitional activity solely for their personal wellbeing to being an act of devotional responsibility. Similarly, in this study, it appeared that people who view others in their life as being highly reliant on them are more likely to engage in treatment; they may be more likely to attend sessions regularly because they know that other people are counting on them to work toward recovery.
For clinical participants, both the awareness (β = -1.07, p = .002) and importance (β = -
1.06, p = .01) subscales of mattering showed significant inverse relations to perceived symptom severity. Clinical participants who perceived themselves as acknowledged by and important to others were likely to experience lower perceived symptom severity. Those who perceived others as unaware of their presence or unconcerned about their life were likely to report greater perceived symptom severity. The reliance subscale of mattering was not significantly related to perceived symptom severity, β = 0.02, p = .95. When all three mattering subscales were TREATMENT ENGAGEMENT IN A PSYCHOLOGY CLINIC 44 simultaneously entered into the prediction model, only the awareness subscale maintained a significant, negative relation to perceived symptom severity, β = -0.99, p = .03.The importance subscale dropped out of significance, β = -0.47, p = .35. This suggests that the awareness component of mattering explains the majority of the variance in perceived symptom severity.
People who report high perceived symptom severity seem to believe that others do not acknowledge their presence.
Strengths and Limitations
The study has several strengths. First, this study was unique in its inclusion of a clinical sample and non-clinical sample obtained from the same academic institution. Utilizing samples obtained from the same undergraduate population allowed for direct comparisons to be made between the two groups on all psychological variables included in this study. This allowed for all results to be contextualized and left no questions as to whether the results in the clinical sample were distinct from those of the general college population. Second, this study utilized an objective, behavioral measure of treatment engagement. The data was collected from an archival data set comprised of a medical record system utilized at the on-campus clinic. This approach eliminated many of the limitations imposed by retrospective self-report; many studies of mental health service use (Bonabi et al., 2016; Eisenberg et al., 2011; Sirey et al., 2001; Vogel et al.,
2006) rely on self-report and/or categorize mental health service use in two groups (i.e., yes/no) rather than in a continuous manner that has more clinical utility.
The present study has several limitations that also warrant consideration. First, the non- clinical group was created on the basis of self-reported treatment history. It may be that some individuals in the non-clinical group were treatment positive. Second, the study utilized a largely homogenous sample, with the majority across both samples identifying as Caucasian (78.5%) TREATMENT ENGAGEMENT IN A PSYCHOLOGY CLINIC 45 and female (69.1%). The sample’s racial and ethnic distribution is representative of the university from which data was collected, however the results may not generalize to more diverse academic institutions.
Implications and Future Directions
The current study differed from many studies of help-seeking stigma, perceived symptom severity, and mattering in that it examined their individual and joint effects on treatment engagement within a campus-based psychology clinic and contextualized these findings by including a non-clinical sample recruited from the same university. The present study provides important information that has the potential to guide both mental health service advocacy and efforts to reduce premature termination. First, over one-third of non-treatment seeking college students in this study scored within the clinically significant range on the objective symptom measure; these students have access to no-cost, campus-based psychiatric and psychological services yet are failing to take advantage of these resources. Given the negative association that emerged between mattering and self-stigma, there appears to be wisdom in future research examining this link as interventions that increase mattering may lead to increased mental health service utilization. Second, findings from this study suggest that high levels of perceived mattering are related to increased treatment engagement in a university psychology clinic. Future research on mattering within clinical samples would benefit from assessing clients at different time points during therapy to examine if/how mattering to others evolves over time within therapeutic work. Finally, results suggest that clinics with high rates of premature termination might benefit from brief interventions focused on increasing clients’ perceived mattering to others; an additional avenue for future research would be to explore what kinds of interventions can modify people’s perception of mattering to others. TREATMENT ENGAGEMENT IN A PSYCHOLOGY CLINIC 46
References
Al-Jabari, R., Murrell, A. R., Callahan, J. L., Cox, R. J., & Lester, E. G. (2018). Do distress level
and waitlists impact termination in a training clinic? Training and Education in
Professional Psychology, 13, 127-137. http://dx.doi.org/10.1037/tep0000223
American College Health Association. American College Health Association-National College
Health Assessment II: Undergraduate Reference Group Executive Summary Fall 2018.
Silver Spring, MD: American College Health Association; 2018. Retrieved from
https://www.acha.org/NCHA/ACHA-NCHA_Data/Publications_and_Reports/NCHA/
Data/Reports_ACHA-NCHAIIc.aspx
Andrade, L. H., Alonso, J., Mneimneh, Z., Wells, J. E., Al-Hamzawi, A., Borges, G., Bromet, E.,
Bruffaerts, R., de Girolamo, G., de Graaf, R., Florescu, S., Gureje, O., Hinkov, H. R., Hu,
C. Huang, Y., Hwang, I., Jin, R., Karam, E. G., Kovess-Masfety, V., . . . Kessler, R. C.
(2014). Barriers to mental health treatment: Results from the WHO world mental health
surveys. Psychological Medicine, 44, 1303-1317.
https://doi.org/10.1017/S0033291713001943
Atkey, S. (2015). Mattering, anti-mattering, and self-stigma of seeking help for mental health
concerns in high school students. Retrieved from
https://yorkspace.library.yorku.ca/xmlui/bitstream/handle/10315/32139/Atkey_Sarah_K_
2015_Masters.pdf?sequence=2&isAllowed=y
Bonabi, H., Müller, M., Ajdacic-Gross, V., Eisele, J., Rodgers, S., Seifritz, E., . . . Rüsch, N.
(2016). Mental health literacy, attitudes to help seeking, and perceived need as predictors
of mental health service use: A longitudinal study. Journal of Nervous and Mental
Disease, 204, 321-324. https://doi.org/10.1097/nmd.0000000000000488 TREATMENT ENGAGEMENT IN A PSYCHOLOGY CLINIC 47
Cadigan, J. M., Lee, C. M., & Larimer, M. E. (2019). Young adult mental health: A prospective
examination of service utilization, perceived unmet service needs, attitudes and barriers
to service use. Prevention Science, 20, 366-376.
https://doi.org/10.1007/s11121-018-0875-8
Callahan, J. L., Aubuchon-Endsley, N., Borja, S. E., & Swift, J. K. (2009). Pretreatment
expectancies and premature termination in a training clinic environment. Training and
Education in Professional Psychology, 3, 111-119. https://doi.org/10.1037/a0012901
Callahan, J. L., Gustafson, S., Misner, J., Paprocki, C. M., Sauer, E., Saules, K. K., . . . Wise, E.
H. (2014). Introducing the Association of Psychology Training Clinics’ collaborative
research network: A study on client expectancies. Training and Education in
Professional Psychology, 8, 95-104. https://doi.org/10.1037/tep0000047
Center for Collegiate Mental Health. (2016, January). 2015 Annual Report (Publication No. STA
15-108). Retrieved from https://files.eric.ed.gov/fulltext/ED572760.pdf
Cha, M. (2016). The mediation effect of mattering and self-esteem in the relationship between
socially prescribed perfectionism and depression: Based on the social disconnection
model. Personality and Individual Differences, 88, 148-159.
https://doi.org/10.1016/j.paid.2015.09.008
Cohen, R. J., & Swerdlik, M. (2010). Psychological testing and assessment: An introduction to
tests and measurement. Columbus, OH: McGraw-Hill.
Corrigan, P. W. (2004). How stigma interferes with mental health care. American Psychologist,
59, 614-625. https://doi.org/10.1037/0003-066x.59.7.614
Corrigan, P. W., Larson, J. E., & Rüsch, N. (2009). Self-stigma and the “why try” effect: impact
on life goals and evidence-based practices. World Psychiatry, 8, 75-81. TREATMENT ENGAGEMENT IN A PSYCHOLOGY CLINIC 48
https://doi.org/10.1002/j.2051-5545.2009.tb00218.x
Corrigan, P. W., Watson, A. C., & Barr, L. (2006). The self-stigma of mental illness:
Implications for self-esteem and self-efficacy. Journal of Social and Clinical Psychology,
25, 875-884. https://doi.org/10.1521/jscp.2006.25.8.875
Dixon, S. K., & Kurpius, S. (2008). Depression and college stress among university
undergraduates: Do mattering and self-esteem make a difference? Journal of College
Student Development, 49, 412-424. https://doi.org/10.1353/csd.0.0024
Drum, D. J., Brownson, C., Burton Denmark, A., & Smith, S. E. (2009). New data on the nature
of suicidal crises in college students: Shifting the paradigm. Professional Psychology:
Research and Practice, 40, 213-222. https://doi.org/10.1037/a0014465
Eisenberg, D., Golberstein, E., & Gollust, S. E. (2007). Help-seeking and access to mental health
care in a university student population. Medical Care, 45, 594-601.
https://doi.org/10.1097/mlr.0b013e31803bb4c1
Eisenberg, D., Hunt, J., Speer, N., & Zivin, K. (2011). Mental health service utilization among
college students in the United States. Journal of Nervous and Mental Disease, 199, 301-
308. https://doi.org/10.1097/nmd.0b013e3182175123
Elliot, G. C., Colangelo, M. F., & Gelles, R. J. (2005). Mattering and suicide ideation:
Establishing and elaborating a relationship. Social Psychology Quarterly, 68, 223-238.
https://doi.org/10.1177/019027250506800303
Elliot, G. C., Kao, S., & Grant, A. (2004). Mattering: Empirical validation of a social-
psychological concept. Self and Identity, 3, 339-354.
https://doi.org/10.1080/13576500444000119 TREATMENT ENGAGEMENT IN A PSYCHOLOGY CLINIC 49
Erekson, D. M., Lambert, M. J., & Eggett, D. L. (2015). The relationship between session
frequency and psychotherapy outcome in a naturalistic setting. Journal of Consulting and
Clinical Psychology, 83, 1097-1107. https://doi.org/10.1037/a0039774
Flett, G. L., Galfi-Pechenkov, I., Molnar, D. S., Hewitt, P. L., & Goldstein, A. L. (2012).
Perfectionism, mattering, and depression: A mediational analysis. Personality and
Individual Differences, 52, 828-832. https://doi.org/10.1016/j.paid.2011.12.041
Francis, J., Rikard, R. V., Cotten, S. R., & Kadylak, T. (2019). Does ICT use matter? How
information and communication technology use affects perceived mattering among a
predominantly female sample of older adults residing in retirement communities.
Information, Communication and Society, 22, 1281-1294.
https://doi.org/10.1080/1369118x.2017.1417459
Gibbons, M. B. C., Rothbard, A., Farris, K. D., Stirman, S. W., Thompson, S. M., Scott, K., . . .
Crits-Christoph, P. (2011). Changes in psychotherapy utilization among consumers of
services for major depressive disorder in the community mental health system.
Administration and Policy in Mental Health and Mental Health Services Research, 38,
495-503. https://doi.org/10.1007/s10488-011-0336-1
Holdsworth, E., Bowen, E., Brown, S., & Howat, D. (2014). Client engagement in
psychotherapeutic treatment and associations with client characteristics, therapist
characteristics, and treatment factors. Clinical Psychology Review, 34, 428-450.
https://doi.org/10.1016/j.cpr.2014.06.004
Lambert, M., Burlingame, G. M., Umphress, V., Hansen, N. B., Vermeersch, D., Clouse, G. C.,
& Yanchar, S. C. (1996). The reliability and validity of the outcome questionnaire. TREATMENT ENGAGEMENT IN A PSYCHOLOGY CLINIC 50
Clinical Psychology and Psychotherapy, 3, 249-258. https://doi.org/10.1002/(sici)1099-
0879(199612)3:4<249::aid-cpp106>3.3.co;2-j
Leichsenring, F., & Rabung, S. (2008). Effectiveness of long-term psychodynamic
psychotherapy: A meta-analysis. Journal of the American Medical Association, 300,
1551-1565. https://doi.org/10.1007/978-1-60761-792-1_3
Lien, Y., Chang, H., Kao, Y., Tzeng, N., Yeh, C., & Loh, C. (2017). Self-stigma mediates the
impact of insight on current suicide ideation in suicide attempters with schizophrenia:
Results of a moderated mediation approach. Suicide and Life Threatening Behavior, 48,
661-676. https://doi.org/10.1111/sltb.12384
Link, B. G. (1987). Understanding labeling effects in the area of mental disorders: An
assessment of the effects of expectations of rejection. American Sociological Review, 52,
96-112. https://doi.org/10.2307/2095395
Lipson, S. K., & Lattie, E. G. (2019). Increased rates of mental health service utilization by U.S.
college students: 10-year population-level trends (2007-2017). Psychiatric Services, 70,
60-63. https://doi.org/10.1176/appi.ps.201800332
Livingston, J. D., & Boyd, J. E. (2010). Correlates and consequences of internalized stigma for
people living with mental illness: A systematic review and meta-analysis. Social Science
and Medicine, 71, 2150-2161. https://doi.org/10.1016/j.socscimed.2010.09.030
Lysaker, P. H., Kukla, M., Vohs, J., L., Schnakenberg Martin, A. M., Buck, K. D., & Ohayon, I.
H. (2019). Metacognition and recovery in schizophrenia: From research to the
development of metacognitive reflection and insight therapy. Journal of Experimental
Psychopathology, 10. https://doi.org/10.1177/2043808718814992 TREATMENT ENGAGEMENT IN A PSYCHOLOGY CLINIC 51
Lysaker, P. H., Vohs, J., Hillis, J. D., Kukla, M., Popolo, R., Salvatore, G., & Dimaggio, G.
(2013). Poor insight into schizophrenia: Contributing factors, consequences and emerging
treatment approaches. Expert Review of Neurotherapeutics, 13, 785-793.
https://doi.org/10.1586/14737175.2013.811150
Marks, K. A., Fastenau, P. S., Lysaker, P. H., & Bond, G. R. (2000). Self-Appraisal of Illness
Questionnaire (SAIQ): Relationship to researcher-rated insight and neuropsychological
function in schizophrenia. Schizophrenia Research, 45, 203-211.
https://doi.org/10.1016/s0920-9964(99)00208-x
Marshall, S. K., & Tilton-Weaver, L. (2019). Adolescents’ perceived mattering to parents and
friends: Testing cross-lagged associations with psychosocial well-being. International
Journal of Behavioral Development, 1-12. https://doi.org/10.1177/0165025419844019
Osborne, J., & Overbay, A. (2004). The power of outliers (and why researchers should always
check for them). Practical Assessment, Research & Evaluation, 9, 1-12.
https://doi.org/10.7275/qf69-7k43
Pernice, F. M., Biegel, D. E., Kim, J. Y., & Conrad-Garrisi, D. (2017). The mediating role of
mattering to others in recovery and stigma. Psychiatric Rehabilitation Journal, 40, 395-
404. https://doi.org/10.1037/prj0000269
Rayle, A. D. (2006). Mattering to others: Implications for the counseling relationship. Journal of
Counseling and Development, 84, 483-487. https://doi.org/10.1002/j.1556-
6678.2006.tb00432.x
Ridgway, P. (2001). Restorying psychiatric disability: Learning from first person recovery
narratives. Psychiatric Rehabilitation Journal, 24, 335-343.
https://doi.org/10.1037/h0095071 TREATMENT ENGAGEMENT IN A PSYCHOLOGY CLINIC 52
Rosenberg, M., & McCullough, B. C. (1981). Mattering: Inferred significance and mental health
among adolescents. Research in Community and Mental Health, 2, 163-182.
Rosenfield, S. (1997). Labeling mental illness: The effects of received services and perceived
stigma on life satisfaction. American Sociological Review, 62, 660-672.
https://doi.org/10.2307/2657432
Rodin, J., & Langer, E. J. (1977). Long-term effects of a control-relevant intervention with the
institutionalized aged. Journal of Personality and Social Psychology, 35, 897–902.
https://doi.org/10.1037/0022-3514.35.12.897
Shannon, A., Flett, G. L., & Goldberg, J. O. (2020). Feelings of not mattering, perceived
stigmatization for seeking help, and help-seeking attitudes among university students.
International Journal of Mental Health and Addiction, 18, 1294-1303.
Sherbourne, C. D., & Stewart, A. L. (1991). The MOS social support survey. Social Science and
Medicine, 32, 705-714. https://doi.org/10.1016/0277-9536(91)90150-b
Sirey, J. A., Bruce, M. L., Alexopoulos, G. S., Perlick, D. A., Friedman, S. J., & Meyers, B. S.
(2001). Stigma as a barrier to recovery: Perceived stigma and patient-rated severity of
illness as predictors of antidepressant drug adherence. Psychiatric Services, 52, 1615-
1620. https://doi.org/10.1176/appi.ps.52.12.1615
Spirito, A., Boergers, J., Donaldson, D., Bishop, D., & Lewander, W. (2002). An intervention
trial to improve adherence to community treatment by adolescents after a suicide attempt.
Journal of the American Academy of Child and Adolescent Psychiatry, 41, 435-442.
https://doi.org/10.1097/00004583-200204000-00016 TREATMENT ENGAGEMENT IN A PSYCHOLOGY CLINIC 53
Swift, J. K., Callahan, J., & Levine, J. C. (2009). Using clinically significant change to identify
premature termination. Psychotherapy: Theory, Research, Practice, Training, 46, 328-
335. https://doi.org/10.1037/a0017003
Swift, J. K., Whipple, J. L., & Sandberg, P. (2012). A prediction of initial appointment
attendance and initial outcome expectations. Psychotherapy: Theory, Research, Practice,
Training, 49, 549-556. https://doi.org/10.1037/a0029441
Taylor, J., & Turner, R. J. (2001). A longitudinal study of the role and significance of mattering
to others for depressive symptoms. Journal of Health and Social Behavior, 42, 310-325.
https://doi.org/10.2307/3090217
Thomas, S. P. (2011). What is mattering and how does it relate to mental health? Issues in
Mental Health Nursing, 32, 485. https://doi.org/10.3109/01612840.2011.588044
Tucker, C., Dixon, A., & Griddine, K. (2010). Academically successful African American male
urban high school students’ experiences of mattering to others at school. Professional
School Counseling, 14, 135-145. https://doi.org/10.5330/prsc.14.2.k215671rj018g134
Tukey, J. W., & McLaughlin, D. H. (1963). Less vulnerable confidence and significance
procedures for location based on a single sample: Trimming/winsortization 1. The Indian
Journal of Statistics, 25, 331-352.
Vogel, D. L., Wade, N. G., & Haake, S. (2006). Measuring the self-stigma associated with
seeking psychological help. Journal of Counseling Psychology, 53, 325-337.
https://doi.org/10.1037/0022-0167.53.3.325
Vogel, D. L., Wade, N. G., & Hackler, A. H. (2007). Perceived public stigma and willingness to
seek counseling: The mediating roles of self-stigma and attitudes toward counseling. TREATMENT ENGAGEMENT IN A PSYCHOLOGY CLINIC 54
Journal of Counseling Psychology, 54, 40-50. https://doi.org/10.1037/0022-
0167.54.1.40
Wang, P. S., Aguilar-Gaxiola, S., Alonso, J., Angermeyer, M. C., Borges, G., Bromet, E. J., . . .
Wells, J. E. (2007). Worldwide use of mental health services for anxiety, mood, and
substance disorders: Results from 17 countries in the WHO World Mental Health
Surveys (WMH) Surveys. The Lancet, 370, 841-850. https://doi.org/10.1016/s0140-
6736(07)61414-7
Webb, T. L., & Sheeran, P. (2006). Does changing behavioral intentions engender behavior
change? A meta-analysis of the experimental evidence. Psychological Bulletin, 132, 249-
268. https://doi.org/10.1037/0033-2909.132.2.249
Wiertzbicki, M., & Pekarik, G. (1993). A meta-analysis of psychotherapy dropout. Professional
Psychology: Research and Practice, 24, 190-195. https://doi.org/10.1037//0735-
7028.24.2.190
Wood, A., Trainor, G., Rothwell, J., Moore, A., & Harrington, R. (2001). Randomized trial of
group therapy for repeated deliberate self-harm in adolescents. Journal of the American
Academy of Child and Adolescent Psychiatry, 40, 1246-1253.
https://doi.org/10.1097/00004583-200111000-00003
Yuan, S. N. V., Kwok, K. H. R., & Ougrin, D. (2019). Treatment engagement in specific
psychological treatment vs. Treatment as usual for adolescents with self-harm:
Systematic review and meta-analysis. Frontiers in Psychology, 10.
https://doi.org/10.3389/fpsyg.2019.00104
TREATMENT ENGAGEMENT IN A PSYCHOLOGY CLINIC 55
Tables
Table 1
Sample Demographics Clinical Sample Non-Clinical Sample Characteristic (n = 134) (n = 112) Gender Male (n %) 37 (27.61) 38 (33.93) Female (n %) 96 (71.64) 74 (66.07) Non-binary (n %) 1 (0.75) 0 (0) Age (years) 19.80 + 1.34 19.79 + 1.12 Year in School First Year (n %) 33 (24.63) 23 (20.54) Sophomore (n %) 43 (32.09) 38 (33.93) Junior (n %) 32 (23.88) 33 (29.46) Senior (n %) 25 (18.66) 17 (15.18) Fifth Year or Above (n %) 1 (0.75) 1 (0.90) Race/Ethnicity Caucasian (n %) 113 (84.33) 80 (71.43) African American (n %) 7 (5.22) 8 (7.14) Hispanic/Latino (n %) 4 (2.99) 7 (6.25) Asian/Pacific Islander (n %) 6 (4.48) 7 (6.25) Bi-racial (n %) 3 (2.24) 7 (6.25) Other Write-in (n %) 1 (0.75) 3 (2.68)
TREATMENT ENGAGEMENT IN A PSYCHOLOGY CLINIC 56
Table 2
Mean Scores of All Study Variables by Sample Clinical Non-Clinical (n = 134) (n = 112)
Variable M (SD) M (SD) PLATSQ 4.37 (0.79) PLATNQ 3.25 (1.09) SSOSHa* 19.78 (5.19) 22.12 (6.40) MTOQ* 86.44 (12.51) 91.54 (11.63) SAIQ-R** 18.72 (2.84) 13.79 (3.27) OQ-45** 76.19 (19.56) 56.95 (22.29) Note: PLATSQ = Perceived Likelihood of Attending Therapy Sessions Questionnaire; PLATNQ = Perceived Likelihood of Attending Therapy Non-Clinical Questionnaire; SSOSH = Self- Stigma of Seeking Help Scale; MTOQ = Mattering to Others Questionnaire; SAIQ-R = Self- Appraisal of Illness Questionnaire-Revised; OQ-45 = Outcome Questionnaire 45.a Data presented utilizes the 9-item version of the SSOSH. * p < .01; ** p < .001
TREATMENT ENGAGEMENT IN A PSYCHOLOGY CLINIC 57
Table 3
Perceived Likelihood of Pursuing Treatment and Source of Services Non-Clinical Sample (n = 112) Item Frequency (n) % Likelihood of seeking mental health services
Extremely Unlikely 2 1.8 Unlikely 39 34.8 Neither 10 8.9 Likely 51 45.5 Extremely Likely 10 8.9 Reported source of potential help seeking
Therapy from on-campus counseling center 88 78.6 Therapy from on-campus training clinic 42 37.5 Medication from on-campus psychiatry 22 19.6 Off-campus/community provider 15 13.4 Note: Participants could select more than one source of mental health service.
TREATMENT ENGAGEMENT IN A PSYCHOLOGY CLINIC 58
Table 4
Univariate Tests of Demographic Factors Relation to Treatment Engagement Clinical Participants (n = 134) Variable B SE Wald Sig Exp(B) CI Gender 0.27 0.45 0.36 0.55 1.31 0.54-3.16 Age -0.03 0.16 0.05 0.83 0.97 0.71-1.32 Race/Ethnicity -0.55 0.54 1.03 0.31 0.58 0.20-1.67 Gender coded as male = 1, female = 2 Race/Ethnicity coded as White = 1, Non-White = 2
TREATMENT ENGAGEMENT IN A PSYCHOLOGY CLINIC 59
Table 5
Univariate Logistic Regression Analyses of Theoretical Predictors and Treatment Engagement Clinical Sample (n = 134) Variable B SE Wald Sig Exp(B) CI PLATSQ -0.31 0.31 0.95 0.33 0.74 0.40-1.36 SSOSH 0.01 0.04 0.02 0.90 1.01 0.93-1.09 MTOQ 0.05 0.02 6.30 0.01 1.05 1.01-1.09 SAIQ-R -0.17 0.09 3.92 0.05 0.84 0.71-1.00 OQ-45 -0.02 0.01 2.36 0.13 0.98 0.96-1.01 Note: PLATSQ = Perceived Likelihood of Attending Therapy Sessions Questionnaire; SSOSH = Self-Stigma of Seeking Help Scale (10-item version); MTOQ = Mattering to Others Questionnaire; SAIQ-R = Self-Appraisal of Illness Questionnaire-Revised; OQ-45 = Outcome Questionnaire 45
TREATMENT ENGAGEMENT IN A PSYCHOLOGY CLINIC 60
Table 6
Multivariate Logistic Regression Analyses of Theoretical Predictors and Treatment Engagement Clinical Sample (n = 134) Variable B SE Wald Sig Exp(B) CI Model 1 PLATSQ -0.40 0.37 1.18 0.28 0.67 0.33-1.38 SSOSH -0.06 0.05 1.63 0.20 0.94 0.85-1.04 MTOQ 0.05 0.02 4.31 0.04 1.05 1.00-1.10 SAIQ-R -0.25 0.12 4.40 0.04 0.78 0.62-0.98 OQ-45 0.01 0.02 0.10 0.75 1.01 0.97-1.04 Model 2 PLATSQ -0.36 0.34 1.12 0.29 0.70 0.36-1.36 SSOSH -0.03 0.05 0.30 0.58 0.98 0.89-1.07 MTOQ 0.04 0.02 5.10 0.02 1.04 1.01-1.08 SAIQ-R -0.14 0.10 1.95 0.16 0.87 0.72-1.06 Model 3 PLATSQ -0.32 0.33 0.97 0.33 0.72 0.38-1.38 MTOQ 0.04 0.02 5.23 0.02 1.05 1.01-1.09 SAIQ-R -0.12 0.09 1.69 0.19 0.89 0.74-1.06 Model 4 MTOQ 0.04 0.02 4.64 0.03 1.04 1.00-1.08 SAIQ-R -0.14 0.09 2.36 0.12 0.87 0.73-1.04 Model 5 MTOQ 0.05 0.02 6.30 0.01 1.05 1.01-1.09 Note: PLATSQ = Perceived Likelihood of Attending Therapy Sessions Questionnaire; SSOSH = Self-Stigma of Seeking Help Scale (10-item version); MTOQ = Mattering to Others Questionnaire; SAIQ-R = Self-Appraisal of Illness Questionnaire-Revised; OQ-45 = Outcome Questionnaire 45
TREATMENT ENGAGEMENT IN A PSYCHOLOGY CLINIC 61
Appendix A
DHSBQ
(Note: For the clinical sample, items 1-4 will be extracted from chart review based on the
information provided at the time of intake [e.g., age at time of intake will be used rather than
age at the time of data extraction]. For the clinical sample, items 5-6 will be disregarded.)
DIRECTIONS: Please choose the best response for each question.
1. What is your age in years? ______(Please write in)
2. What is your year in school? A. First year B. Sophomore C. Junior D. Senior E. Fifth year or above F. Other: ______(Please write in)
3. Which gender do you identify with? A. Male B. Female C. Non-binary D. Other: ______(Please write in) E. I would rather not say
4. Which best describes your racial/ethnic identity? A. Caucasian, non-Hispanic B. African American C. Latino or Hispanic D. Asian or Pacific Islander E. American Indian or Alaskan Native F. Bi-racial G. Other: ______(Please write in) H. I would rather not say
5. Have you ever sought services from a mental health professional (e.g., counselor, therapist, psychologist, psychiatrist)? A. Yes B. No
TREATMENT ENGAGEMENT IN A PSYCHOLOGY CLINIC 62
5A. If yes, what forms of mental health services have you received? (Please select ALL that apply) A. Therapy or counseling Yes No B. Medication for mental health reasons Yes No
6. Have you ever had 4 or more sessions within a 2-month period with a mental health service provider (e.g., counselor, therapist, psychologist, psychiatrist)? A. Yes B. No
6A. Have you received therapy at the Xavier Psychological Services Center? (Please check ALL that apply) ____ Currently ____ Last year (Anytime between August 2018 through May 2019) ____ More than one year ago ____ I have never received therapy at the Psychological Services Center.
6B. Have you received therapy at the Counseling Center (i.e., The HUB)? (Please check ALL that apply) ____ Currently ____ Last year (Anytime between August 2018 through May 2019) ____ More than one year ago ____ I have never received therapy at the Counseling Center (i.e., The HUB).
6C. Have you received services from a mental health professional (e.g., counselor, therapist, psychologist, psychiatrist) at an off-campus location? (Please check ALL that apply) ____ Currently ____ Last year (Anytime between August 2018 through May 2019) ____ More than one year ago ____ I have never received mental health services off-campus.
TREATMENT ENGAGEMENT IN A PSYCHOLOGY CLINIC 63
Appendix B
PLATSQ
DIRECTIONS:
1. How likely are you to attend each session that is recommended for you at the Psychological Services Center? a. Extremely unlikely (1) b. Unlikely (2) c. Neutral (3) d. Likely (4) e. Extremely Likely (5)
TREATMENT ENGAGEMENT IN A PSYCHOLOGY CLINIC 64
Appendix C
PLATNQ
1. If you began to notice that you were experiencing mental health symptoms (e.g., depression, anxiety, intense stress, difficulty sleeping), how likely would you be to seek out mental health services (e.g., therapy, counseling, psychiatric medication)?
1 2 3 4 5 Extremely Unlikely Unlikely Neither Likely Extremely Likely
2. If you did seek out mental health services, where would you go? (Please check ALL that apply) a. _____Xavier Psychological Services Center (Sycamore House) for therapy b. _____Counseling Center (i.e., The HUB) for psychiatric medication c. _____Counseling Center (i.e., The HUB) for counseling services d. _____An off-campus mental health service (write-in): ______
TREATMENT ENGAGEMENT IN A PSYCHOLOGY CLINIC 65
Appendix D
SSOSH
DIRECTIONS: People have different beliefs about what seeking psychological help will do (or not do) for them. The following items are designed to indicate your current view of seeking psychological help. Each item is phrased hypothetically (e.g., “if I,” “I would”), though it is recognized that many people filling out this survey are currently interested in beginning therapy at the Psychological Services Center. Please indicate your level of agreement with each statement by marking whether you: Strongly Disagree = 1; Disagree = 2; Neutral = 3; Agree = 4; Strongly Agree = 5
1. I would feel inadequate if I went to a therapist for psychological help. 1 2 3 4 5 Strongly Disagree Neutral Strongly Agree
2. My self-confidence would NOT be threatened if I sought professional help. 1 2 3 4 5 Strongly Disagree Neutral Strongly Agree
3. Seeking psychological help would make me feel less intelligent. 1 2 3 4 5 Strongly Disagree Neutral Strongly Agree
4. My self-esteem would increase if I talked to a therapist. 1 2 3 4 5 Strongly Disagree Neutral Strongly Agree
5. My view of myself would NOT change just because I made the choice to see a therapist. 1 2 3 4 5 Strongly Disagree Neutral Strongly Agree
6. It would make me feel inferior to ask a therapist for help. 1 2 3 4 5 Strongly Disagree Neutral Strongly Agree TREATMENT ENGAGEMENT IN A PSYCHOLOGY CLINIC 66
7. I would feel okay about myself if I made the choice to seek professional help. 1 2 3 4 5 Strongly Disagree Neutral Strongly Agree
8. If I went to a therapist, I would be less satisfied with myself. 1 2 3 4 5 Strongly Disagree Neutral Strongly Agree
9. My self-confidence would remain the same if I sought help for a problem I could not solve. 1 2 3 4 5 Strongly Disagree Neutral Strongly Agree
10. I would feel worse about myself if I could NOT solve my own problems. 1 2 3 4 5 Strongly Disagree Neutral Strongly Agree
TREATMENT ENGAGEMENT IN A PSYCHOLOGY CLINIC 67
Appendix E
MTOQ
DIRECTIONS: Though we do not necessarily know other people’s thoughts, oftentimes we may have ideas or feelings about how other people perceive us. The following items will indicate how you think that other people think about you. In answering the following questions, try not to think about specific others in your life; instead, think about other people in general. Please indicate your level of agreement with each statement by marking whether you: Strongly Disagree = 1; Disagree = 2; Neutral = 3; Agree = 4; Strongly Agree = 5
1. Most people do not seem to notice when I come or when I go. 1 2 3 4 5 Strongly Disagree Neutral Strongly Agree
2. In a social gathering, no one recognizes me. 1 2 3 4 5 Strongly Disagree Neutral Strongly Agree
3. Sometimes when I am with others, I feel almost as if I were invisible. 1 2 3 4 5 Strongly Disagree Neutral Strongly Agree
4. People are usually aware of my presence. 1 2 3 4 5 Strongly Disagree Neutral Strongly Agree
5. For whatever reason, it is hard for me to get other people’s attention. 1 2 3 4 5 Strongly Disagree Neutral Strongly Agree
6. Whatever else may happen, people do not ignore me. 1 2 3 4 5 Strongly Disagree Neutral Strongly Agree
TREATMENT ENGAGEMENT IN A PSYCHOLOGY CLINIC 68
7. For better or worse, people generally know when I am around. 1 2 3 4 5 Strongly Disagree Neutral Strongly Agree
8. People tend not to remember my name. 1 2 3 4 5 Strongly Disagree Neutral Strongly Agree
9. People do not care what happens to me. 1 2 3 4 5 Strongly Disagree Neutral Strongly Agree
10. There are people in my life who react to what happens to me in the same way they would if it had happened to them. 1 2 3 4 5 Strongly Disagree Neutral Strongly Agree
11. My successes are a source of pride to people in my life. 1 2 3 4 5 Strongly Disagree Neutral Strongly Agree
12. I have noticed that people will sometimes inconvenience themselves to help me. 1 2 3 4 5 Strongly Disagree Neutral Strongly Agree
13. When I have a problem, people usually don’t want to hear about it. 1 2 3 4 5 Strongly Disagree Neutral Strongly Agree
14. Much of the time, other people are indifferent to my needs. 1 2 3 4 5 Strongly Disagree Neutral Strongly Agree
TREATMENT ENGAGEMENT IN A PSYCHOLOGY CLINIC 69
15. There are people in my life who care enough about me to criticize me when I need it. 1 2 3 4 5 Strongly Disagree Neutral Strongly Agree
16. There is no one who really takes pride in my accomplishments. 1 2 3 4 5 Strongly Disagree Neutral Strongly Agree
17. No one would notice if one day I disappeared. 1 2 3 4 5 Strongly Disagree Neutral Strongly Agree
18. If the truth be known, no one really needs me. 1 2 3 4 5 Strongly Disagree Neutral Strongly Agree
19. Quite a few people look to me for advice on issues of importance. 1 2 3 4 5 Strongly Disagree Neutral Strongly Agree
20. I am not someone people turn to when they need something. 1 2 3 4 5 Strongly Disagree Neutral Strongly Agree
21. People tend to rely on me for support. 1 2 3 4 5 Strongly Disagree Neutral Strongly Agree
22. When people need help, they come to me. 1 2 3 4 5 Strongly Disagree Neutral Strongly Agree
TREATMENT ENGAGEMENT IN A PSYCHOLOGY CLINIC 70
23. People count on me to be there in times of need. 1 2 3 4 5 Strongly Disagree Neutral Strongly Agree
24. Often people trust me with things that are important to them. 1 2 3 4 5 Strongly Disagree Neutral Strongly Agree
TREATMENT ENGAGEMENT IN A PSYCHOLOGY CLINIC 71
Appendix F
SAIQ-R
DIRECTIONS: People can experience all different types of problems in their daily lives. People can also have a unique understanding of their own problems. Think about the life difficulties that you are currently experiencing and with those in mind, please answer the following questions. Check the choice that best reflects your personal understanding.
1. If someone recommended mental health treatment for your problems, how would you feel about this person’s recommendation?
a. Strongly agree _____ b. Agree _____ c. Disagree _____ d. Strongly disagree _____
2. I can gain a lot from being in mental health treatment.
a. Strongly agree _____ b. Agree _____ c. Disagree _____ d. Strongly disagree _____
3. I think my problems require psychiatric treatment.
a. Strongly agree _____ b. Agree _____ c. Disagree _____ d. Strongly disagree _____
4. I have symptoms of mental illness.
a. Strongly agree _____ b. Agree _____ c. Disagree _____ d. Strongly disagree _____
5. Do you believe you need mental health treatment for your current problems?
a. Definitely _____ b. Probably _____ c. Probably not _____ d. Definitely not _____
TREATMENT ENGAGEMENT IN A PSYCHOLOGY CLINIC 72
6. If you did not receive mental health treatment, how do you think you would be doing?
a. Doing very poorly _____ b. Doing poorly _____ c. Doing well _____ d. Doing very well _____
TREATMENT ENGAGEMENT IN A PSYCHOLOGY CLINIC 73
Appendix G
OQ-45
The Outcome Questionnaire 45 (OQ-45; Lambert et al., 1996) is protected by copyright so it is not reproduced in this document. The measure is available through OQ Measures.
TREATMENT ENGAGEMENT IN A PSYCHOLOGY CLINIC 74
Appendix H
Treatment Engagement Capture Form
(Note: The following form will be completed by the researcher for clinical sample participants only. Data will be extracted via chart review.)
Study ID: ______
Did the client attend their scheduled intake appointment?
Yes No
(If marked “no,” disregard remaining items.)
Date of first scheduled session: ______(format: MM/DD/YY)
Date of first scheduled session + 60 days (excluding days when university classes are not in session): ______(format: MM/DD/YY)
Number of sessions scheduled with the first 8 weeks of treatment: ______
Number of sessions attended within the first 8 weeks of treatment: ______
Did the client attend at least four sessions within the first 8 weeks of treatment (including the first scheduled session)?
Yes No
Did the client attend any additional sessions after the first 8 weeks of treatment?
Yes No
TREATMENT ENGAGEMENT IN A PSYCHOLOGY CLINIC 75
Appendix I
TREATMENT ENGAGEMENT IN A PSYCHOLOGY CLINIC 76
Appendix J
Table 7
Non-Clinical Participants’ Demographic and Study Variables by Subsample In-person Fully remote Variable (n = 64) (n = 48) p Gender 0.49 Male (n %) 20 (31.25) 18 (37.5) Female (n %) 44 (68.75) 30 (62.5) Age (years) 19.83 + 1.14 19.73 + 1.11 0.87 Race/Ethnicity 0.61 Caucasian (n %) 45 (70.31) 35 (72.92) African American (n %) 4 (6.25) 4 (8.33) Hispanic/Latino (n %) 4 (6.25) 3 (6.25) Asian/Pacific Islander (n %) 3 (4.69) 4 (8.33) Bi-racial (n %) 5 (7.81) 2 (4.17) Other Write-in (n %) 3 (4.69) 0 (0) PLATNQ 3.17 + 1.12 3.35 + 1.04 0.41 SSOSHa 22.92 + 6.84 21.04 + 5.67 0.21 MTOQ 92.41 + 12.74 90.38 + 9.98 0.41 SAIQ-R 14.23 + 3.24 13.21 + 3.26 0.82 OQ-45 59.69 + 24.03 53.29 + 19.36 0.13 Note: PLATNQ = Perceived Likelihood of Attending Therapy Non-Clinical Questionnaire; SSOSH = Self-Stigma of Seeking Help Scale; MTOQ = Mattering to Others Questionnaire; SAIQ-R = Self-Appraisal of Illness Questionnaire-Revised; OQ-45 = Outcome Questionnaire 45 aData presented utilizes the 9-item version of the SSOSH; comparability of continuous variables was assessed using independent samples t-tests; comparability of categorical variables was assessed using Chi-Square tests of independence.
TREATMENT ENGAGEMENT IN A PSYCHOLOGY CLINIC 77
Summary
Title: Effect of Help-Seeking Stigma, Perceived Symptom Severity, and Perceived Mattering on
Treatment Engagement in a University Psychology Training Clinic
Problem. 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 et al., 2019). Even when treatment is pursued, the dosage and duration appear insufficient to affect meaningful change. According to the Center for Collegiate
Mental Health 2015 Annual Report, the modal number of psychotherapy sessions for college students is one. 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.
Method. The final sample (N = 246) included 69.1% (n = 170) women and was 78.5%
Caucasian, non-Hispanic (n = 193). The mean age of participants was 19.79 years. Participants were stratified across year in school: 22.8% first years (n = 56), 32.9% sophomores (n = 81),
26.4% juniors (n = 65), 17.1% seniors (n = 42), and 0.8% fifth years (n = 2). A clinical subsample consisted of 134 participants who initiated psychological treatment at the campus- based clinic. The other 112 participants were recruited to serve as a comparison sample. Neither age, gender, nor ethnicity significantly varied across the two subsamples. All participants completed measures of help-seeking stigma, mattering to others, and perceived symptom severity. For the clinical sample, these measures were completed prior to intake. Treatment engagement was defined as attending four or more therapy sessions within the first two months of beginning treatment. TREATMENT ENGAGEMENT IN A PSYCHOLOGY CLINIC 78
Findings. 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 of
MANOVA indicated clinical participants reported significantly lower help-seeking stigma, F(1,
239) = 9.76, p = .002, higher perceived symptom severity, F(1, 239) = 156.76, p < .001, and lower perceived mattering to others, F(1, 239) = 10.61, p = .001, pretreatment compared to participants in the non-clinical sample. Results indicated a significant, moderate, negative correlation between mattering and help-seeking stigma in the comparison sample, r(110) = -.54, p < .001, but not in the clinical sample, r(127) = -.07, p = .44; non-clinical participants who reported greater subjective mattering to others were less likely to report perceived help-seeking stigma, but in the clinical sample mattering to others and help-seeking stigma were not related. 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.
Implications. The present study has the potential to guide both mental health service advocacy and efforts to reduce premature termination. Future research should further examine the negative association between mattering and self-stigma as interventions that increase mattering may lead to increased mental health service utilization. Findings from this study suggest that high levels of perceived mattering are related to increased treatment engagement in a university psychology clinic. Future research on mattering within clinical samples would benefit from assessing clients at different time points during therapy to examine if/how mattering to others evolves over time within therapeutic work and explore brief interventions for increasing clients’ perceived mattering to others.