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4-17-2019 Marriage and Family Therapist Websites: A Qualitative Content Analysis Thomas Bischoff University of Connecticut - Storrs, [email protected]

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Marriage and Family Therapist Websites: A Qualitative Content Analysis

Thomas Bischoff, Ph.D.

University of Connecticut, 2019

The positive benefits of therapy are well-established (Duberstein et al., 2018) and therapy continues to make significant strides with regard to therapeutic outcomes. However, little is known regarding client initiation processes as well as how therapists reach out to potential clients. Clients present with a variety of challenges, and researchers and clinicians struggle with creating ways to increase access to care, reach out to potential clients, and engage individuals in therapy services. Nevertheless, therapist engagement and connection with the client can have a significant impact (Sexton, Littauer, Sexton, & Tømmerås, 2005). Marriage and Family

Therapists (MFTs) are uniquely trained and qualified to develop strong therapeutic relationships with multiple clients at the same time (Blow & Sprenkle, 2001). As a rapidly growing field that is competing against other professional counseling services, it is crucial to understand how MFTs reach out to clients and potential clients. This study addressed this research gap by conducting a qualitative content analysis of MFT websites in order to better understand what and how therapists are passively marketing to potential clients. Twenty-five websites were selected from

Psychology Today. Matrices were used to organize the website data and commence the analysis process. Next, each website was uploaded into Linguistic Inquire Word Count (LIWC; Francis &

Booth, 1993), a text analysis software program. The LIWC program assisted with providing statistical information surrounding pre-established categories. Then, the websites were uploaded into Dedoose (Dedoose Software, 2014), an online qualitative software program, where coding occurred and themes emerged. Results from the LIWC analysis revealed higher level thinking, a strong demonstration of confidence, and mixed results of authenticity and overall emotional tone.

Thomas Bischoff, University of Connecticut, 2019

Some of the themes from the study included: collaboration, pressure to convey, and negative motivation. Additionally, a lack of MFT branding and description was observed. The findings are discussed, and clinical implications and future research ideas are provided.

Running head: MFT WEBSITES

Marriage and Family Therapist Websites: A Qualitative Content Analysis

Thomas Bischoff

B.I.S., Weber State University, 2012

M.S., Northern Illinois University, 2015

A Dissertation

Submitted in Partial Fulfillment of the

Requirements for the Degree of

Doctor of Philosophy

at the

University of Connecticut

2019

ii

Copyright by

Thomas Bischoff

2019 iii

APPROVAL PAGE

Doctor of Philosophy Dissertation

Marriage and Family Therapist Websites: A Qualitative Content Analysis

Presented by Thomas Bischoff, B.I.S., M.S.

Major Advisor ______Rachel Tambling

Associate Advisor ______Caitlin Lombardi

Associate Advisor ______Maria LaRusso

University of Connecticut 2019 iv

TABLE OF CONTENTS

CHAPTER 1: INTRODUCTION ………………………………………………………………1

CHAPTER 2: LITERATURE REVIEW………………………………………………………..4

CHAPTER 3: METHODOLOGY………………………………………………………………15

CHAPTER 4: RESULTS………………………………………………………………………..34

CHAPTER 5: DISCUSSION……………………………………………………………………63

References: ……………………………………………………………………………………...76

MFT WEBSITES 1

CHAPTER 1: INTRODUCTION

The effectiveness of therapy has been well established (Evertsz et al., 2017; Smith &

Grawe, 2003). Therapy has the capacity to help clients overcome traumatic experiences

(Duberstein et al., 2018), assist those who struggle with anxiety (Lilliengren, Johansson, Town,

Kisely, & Abbass, 2017) and depression (Saloheimo et al., 2016), and improve relationships

(Doss, Mitchell, Georgia, Biesen, & Rowe, 2014). Additionally, therapy is effective among parents (Gattis et al., 2008) and children (Swank & Smith-Adcock, 2018), elderly persons (Payne

& Marcus, 2008), substance users (Wolitzky-Taylor et al., 2018), and a variety of racial and ethnic groups (Greenbaum et al., 2015). There is great diversity in client presentation, and yet little is known about what prompts individuals to seek counseling services. Researchers and clinicians alike struggle to develop ways to increase access to care, reach out to potential clients, and engage individuals, couples, and families in counseling services.

Clients are seeking therapy (Pasley, Rhoden, Visher, & Visher, 1996; Rickwood, Deane,

& Wilson, 2007) and therapists are seeking clients (Colburn, 2013). There is some evidence to indicate that clients engage in a number of steps prior to actually engaging in a first therapy session (Elliot, Westmacott, Hunsley, Rumstein-McKean, & Best, 2005), including identifying a problem area and researching potential treatment options (Doss, Atkins, & Christensen, 2003).

Despite some research that suggest clients engage in some process prior to a first therapy session

(e.g. Doss et al., 2003), virtually nothing is known about how therapists and clients initially engage with each other.

Research has shown that there are significant barriers to client engagement in therapy, such as access (Benevides, Carretta, Ivey, & Lane, 2017) and stigma (Hines-Martin, Malone,

Kim, & Brown-Piper, 2003). Therapists are in a position to reach out and help clients overcome MFT WEBSITES 2 these barriers and assist potential clients in the therapy initiation process. Therapist engagement and connection with the client has significant impact on client participation in therapy (Sexton,

Littauer, Sexton, & Tømmerås, 2005) and the therapeutic alliance (Kazdin, Marciano, &

Whitley, 2005).

Marriage and family therapists (MFT) are a type of therapist uniquely trained and qualified to develop a strong relationship with multiple clients at the same time (Blow &

Sprenkle, 2001; Sprenkle, Blow, & Dickey, 1999). In comparison to individual or mixed psychotherapy modalities, family therapy has been shown to be more cost-effective, more successful, and have lower rates of client relapse (Crane & Payne, 2011). There are over 50,000

MFTs in the United States (AAMFT, 2019a), and the Bureau of Labor Statistics (2019) projects that MFTs will increase in number of licensed professionals by twenty-three percent in the next ten years. The percentage is seven points higher than the combined group of social workers, counselors and other community social service professionals (Bureau of Labor Statistics. 2019), suggesting that MFT is a rapidly growing field. With research demonstrating MFT to be an effective approach to addressing a variety of issues (Carr, 2009a; Carr, 2009b; Lundblad &

Hansson, 2006), and it being a quickly growing discipline (Bureau of Labor Statistics, 2019),

MFT is a prime field to study. Understanding how MFTs reach out and market themselves and their services to potential clients may help develop new ways of reaching potential clients and improve access to services.

Marketing could be an effective way to reach out to potential clients. There are a variety of general marketing strategies that therapists could, and do, employ to reach out to potential clients (Keller, 2009; Roy & Chattopadhyay, 2010; Schmitt, 1999). However, it is not understood what kind of marketing strategies are being used by therapists. Marketing among MFT WEBSITES 3 therapists and specifically MFTs has received little to no attention among researchers.

Additionally, little is known about the passive marketing mechanisms, such as websites, therapists may use to market services to potential clients. Through the investigation of therapist websites, data can be obtained about passive recruitment and marketing mechanisms that lead potential clients to therapy. The following study aims to fill this gap by obtaining greater understanding of MFT passive marking strategies via websites.

MFT WEBSITES 4

CHAPTER 2: LITERATURE REVIEW

Research has clearly demonstrated that therapy effectively helps clients overcome their challenges (Duberstein et al., 2018). Therapy works with persons who suffer from a variety of issues, such as anxiety (Lilliengren et al., 2017), trauma (Duberstein et al., 2018), and depression

(Saloheimo et al., 2016). Additionally, therapy has shown to effectively assist parents (Gattis et al., 2008), children (Swank & Smith-Adcock, 2018), substance users (Wolitzky-Taylor et al.,

2018), and with relationship issues (Doss et al., 2014). Mental health concerns are a primary reason for seeking therapy (Churchhill et al., 2002), yet it is not well understood how clients begin the therapy initiation process. Research suggests that there are steps clients take to enter therapy (Doss et al., 2003), but how clients and therapists eventually engage with one another remains unclear.

In addition, there are significant barriers to client engagement in therapy, such as access

(Benevides et al., 2017) and stigma (Hines-Martin et al., 2003). Therapists are in a position to assist potential clients in the therapy initiation process. Therapist engagement with the client can have a positive impact on the client (Sexton et al., 2005). Reaching out and engaging with potential clients before they enter therapy could positively motivate potential clients to start therapy. Research shows that therapists are seeking clients (Colburn, 2013), and marketing could be a positive and influential way to engage and assist potential clients through the therapy initiation process. Marriage and Family Therapists (MFTs) are uniquely trained to develop strong relationships with clients (Blow & Sprenkle, 2001). Gaining greater understanding for how MFTs market themselves and their services to potential clients may help with client access to therapy services. MFT WEBSITES 5

Research is scarce regarding therapy initiation processes and marketing practices. Client help-seeking behavior is not well-understood, nor are the therapist strategies for reaching out to potential clients. Many people are seeking help and guidance online (PewResearch, 2009), and therapists, including MFTs, are marketing online through the creation and display of professional websites. Research is needed in order to obtain more understanding regarding marketing practices via a professional website. Additionally, more information is needed concerning how

MFTs market themselves, their services, and their field. More knowledge surrounding therapy marketing practices will assist therapists to reach out to potential clients as well as help potential clients initiate therapy and overcome their challenges.

The following section provides a discussion regarding websites and their utilization in modern times. Then, online marketing methods are presented. Next, branding of ideas and products are discussed and related to therapy. Finally, available literature on therapist marketing practices are provided.

Websites

More and more people are online with global reports of over four billion people that have access to and are using the internet (Internet World Stats, 2019). With access to online services via computers, tablets, and smartphones, this has become the way to socialize and even a way of life (Baruah, 2012; Durusoy, Hassoy, & Karababa, 2013; Raine, 2013; United States Census

Bureau, 2012). Online, one can create a persona that reflects who they are, and the profile becomes an artifact that demonstrates one’s existence in the online realm (Ekbia, 2009). With billions of people existing online, society’s culture has become digitally integrated.

The internet is a massive digital world of websites with a primary purpose of providing information (Rosen, Purinton, & Lloyd 2005). The internet has become a place to create, MFT WEBSITES 6 produce, disseminate, and search for knowledge regarding almost anything (Masters, 2008;

Ruzgar, 2005). Lyman and Kahle (1998) proclaimed the internet to be a digital cultural artifact where one can convey cultural ideas and emotions. Cultural artifacts provide information regarding a society’s behavior, relationships, and ultimately their existence (Fletcher & Light,

2007). The artifact should be viewed within a given context as well as the relationship it has with the environment. Furthermore, artifacts elicit memories and feelings associated with the cultural practices occurring at the time of the creation and existence of the artifact (Fletcher & Light,

2007).

Motion (2001) referred to the internet as a communication tool and marketplace.

Researchers report that people participate in online forums and web pages (e.g. blogging) to increase the audience to whom they can promulgate their ideas (Mewburn & Thomson, 2013).

With so many people online and the internet’s capacity to reach users globally, websites become an influential and opportune marketing place to establish a name and product (Tiago &

Veríssimo, 2014). Thus, it makes sense that MFTs have entered the realm of online marketing via professional websites in order to advertise themselves and their services.

Many people are seeking help online for a variety of physical and mental health issues.

Two PewResearch articles provide some insight into the online demographics that indicate help- seeking behavior. PewResearch (2009) reported that roughly 60% of Americans were using the internet to look up general health information. Sometimes they would read blogs, make posts, or sign up to obtain more information (PewResearch, 2009). Another poll found that 80% of online participants looked up a health subject, such as certain illnesses, health insurance information, or nutrition (PewResearch, 2003). The statistics suggests that the internet is an important place to obtain general health information. With regard to mental health, Fox and Jones (2009) found that MFT WEBSITES 7 such online topic searches increased from 22% to 28% between 2006 and 2008. In addition to the mental health search increase, it was discovered that women and emerging adults are the most likely groups to search information about mental health online. However, adults between the ages 30-64 are also significant online participants for mental health searches (Fox & Jones,

2009). Online seeking for mental health is increasing and merits further research and understanding.

Concerns about mental health is a primary reason for why people seek therapy

(Churchhill et al., 2002). It is not well understood if therapists are easily accessible online and are providing information that attracts the client and helps them make an informed decision. It is important to understand the step-by-step process for how a therapy service is discovered and accessed. Additionally, it is worth knowing what influences a potential client to select one therapist or therapy service over another, such as learning about what they like or value, what impresses them, and what turns them away. Answers to these unknowns would provide meaningful information to those working in the field of therapy or mental health, and more importantly, help potential clients more readily access the services they need.

By simply searching online or using specific websites, such as Therapist Locator,

Psychology Today, and Find a Therapist, which are popular therapist search engines, one can discover many options of therapists and therapy services within a given geographic area. Many therapists and agencies have created websites to advertise themselves and their services.

However, it seems unclear as to how these therapists and agencies determined what or how to market. Perhaps the way they are marketing is effective or maybe there are better ways of reaching out to the community. Either way, little is known about the general trends in passive marketing tools, such as websites, used by therapists. MFT WEBSITES 8

Because of its rapid growth and popularity, MFT websites seem ripe for examination in order to determine how they assist potential clients initiate therapy. People are searching and exploring websites, and online marketing can have an influence on one’s business by affecting customer attitudes and thoughts regarding the company (Bačik & Fedorko, 2016). Websites have the capacity to increase knowledge and improve perception of a topic or product (Schofield,

Weis, Ponzini, & McHugh, 2017). However, there is a scarcity of research surrounding therapy marketing practices with little to none focusing on online marketing practices. Examining therapist websites will help to understand and improve marketing practices online. Studying therapist websites will benefit therapists by learning and developing effective marketing practices and disregarding poor marketing strategies. Additionally, better therapist marketing will assist potential clients in finding and engaging in appropriate therapy services, and optimistically, might reduce barriers by demystifying the process.

Marketing

Websites are powerful passive communication tools (Sommerfeldt, Kent, & Taylor,

2012) that serve as a symbolic function for companies (Sommerfeldt et al., 2012). While websites are a frequently accessed source of information, the information presented is not always effective in its presentation (Horrigan, 2008). Other health fields, such as dentistry, discuss the importance of creating a website to market one’s practice (Downes, 2007). MFTs would do well to understand what symbols and messages are being communicated to their audience via their website.

Some students have demonstrated the effectiveness of different tools and active strategies for marketing therapy to potential clients. A counseling clinic in the southern United States focused on improving the community’s perception of the clinic and increasing clientele by using MFT WEBSITES 9 a mix of active and passive marketing strategies (Johnston, 1988). The researcher reported the clinic used three tools: public service announcements, bulletin boards, and graphic art. By comparing clientele numbers before and after implementation of these marketing tools, Johnston

(1988) reported a significant increase in client attendance. It is uncertain as to the specific details of how or why the tools assisted the clinic to increase their caseload or how they provided therapy service awareness for clients. Nevertheless, the study demonstrated the importance of studying marketing in the therapy field and its potential influence for increasing service initiation by prospective clients. The marketing influence is often largely due to the manner in which messages are communicated.

Research surveys have indicated that failure to communicate between a consumer and an agency is a primary reason for losing business (Sutherland, Duke, & Abernathy, 2004). Online marketing has the potential to communicate to large masses of people. However, even in such a trafficked environment there are effective and ineffective ways of marketing online. Kozinets

(2002) reported that a major commitment of marketing research is to learn about what the customer wants and what influences their choices in buyer consumption. It seems that it would benefit MFTs to understand what their target population appreciates and desires in a website.

People have preferences and are attracted to website content and designs (Tullis & Stetson,

2004). Websites need to have a human element by incorporating aspects and features such as humor, graphics, and 3D models (Hauman and Siekpe, 2009). Additionally, website features influence whether a customer views the website as useful, informative, and entertaining (Haman

& Siekpe, 2009). People have an opinion and attraction to certain websites, and research is necessary for understanding client preferences of therapy websites. It is unknown whether current MFT website designs effectively attract clients and persuade them to engage in their MFT WEBSITES 10 services. Additionally, it is not understood if that is even the purpose of these websites. Thus, supporting the need for research on MFT websites.

In another study, nine success factors were found to influence customer engagement with websites (Park & Gretzel, 2007). The success factors included: information quality, ease of use, responsiveness, security/privacy, visual appearance, trust, interactivity, personalization, and fulfillment (Park & Gretzel, 2007). Gerke and Turban (1999) similarly found that successfully selling online was strongly related to the website design. They reported the following factors that increased website viability: page loading speed, business content, navigation efficiency, security, and customer focus (Gerke & Turban, 1999). Again, there are preferences regarding types of online marketing practices (Smith, 2012), and the organizations that create the websites need to meet customer desires in order to gain their trust and loyalty (O’Cass & Carlson, 2012). There is also an increased likelihood that these customers will refer others to the website (O’Cass &

Carlson, 2012). MFTs could benefit from research studies and analyses that examine the quality and effectiveness of their websites. Potential clients may also desire websites that are easy to use, visually appealing, and personable.

Branding

Another marketing study discovered that the quality and brand equity of a website were crucial elements for obtaining consumer confidence and influencing them to order the product

(Chang, Hsu, Chen, & Kuo, 2019). Self-branding is how a person makes themselves known, demonstrating who they are in the marketing world (Shepherd, 2005). Labrecque, Markos, and

Milne (2011) report that being online instantly creates a self-branding process. According to this notion, not only are MFTs generating digital cultural artifacts (Lyman & Kahle, 1998), they have also started a branding process by creating websites, whether intentionally or not. Website MFT WEBSITES 11 qualities like trust and familiarity (Klaus, 2013) increase customer satisfaction and branding effectiveness (Silva & Alwi, 2008). Furthermore, branding practices have been studied in a variety of areas, such as sports (Kwak & Kang, 2009) businesses (Hartmann & Apaolaza-Ibáñes,

2011), journalism (Molyneux, Holton, & Lewis, 2018), and other firms (Ravasi & Rindova,

2008). Therapy could be the next frontier for branding research. Specifically, MFTs could benefit from branding in order to distinguish themselves from other professional therapy services. MFTs need to explain what they do and what their field signifies.

Though well-studied in some areas and fields, branding is newer to others (Edwards,

2010). In order to attract clients and assist them in the decision-making process regarding therapy services, it would serve MFTs to describe themselves and their services, creating an image of what typical MFTs do. MFTs may be over looked because of their unfamiliarity or unestablished identity. Branding is considered an important tool for companies and organizations to create attraction and provide meaning, which in turn can draw people to the services or product being branded (Backhaus & Tikoo, 2004). By establishing a brand, MFTs could create a strong identity that the public understands, respects, and values. The MFT name and the accompanying services need to concoct a meaningful image in the thought and dialogue of those seeking therapy services. Furthermore, establishing a brand will grow the number of people that visit their website as well as increase the number of clients they serve.

Emotional Branding.

There is also an emotional aspect of branding that can influence the success of a company or product. Matching consumer emotions and beliefs with the product can create positive results

(Hartmann, Ibàñez, & Sainze, 2005). Beruchashvili, Moisio, and Gentry (2015) proposed that emotions are very much embedded in cultural behaviors and experiences. Thus, when MFT WEBSITES 12 considering MFT websites, it is important to understand how the therapists portray themselves to the potential client on an emotional level. Emotional branding refers to trust and authenticity, with greater trust and authenticity relating to stronger loyalty from consumers (Rossiter &

Bellman, 2012). Therefore, if the tone of the MFT website is positive and creates a sense of trust and genuineness, then the potential client may be more likely to engage further in therapy services.

MFT services involve working with people who are struggling with mental health

(Churchill et al., 2002), emotional difficulties (Hayes & Feldman, 2004), and/or relational issues

(Doss et al., 2015). Emotions are an important factor in therapy services. One study examined the difference between using emotional branding to fit the consumer’s actual self (how they currently are) or their ideal self (how they would like to be). The study found that using emotional branding to market to the actual self was more effective for attracting consumers

(Malär et al., 2011). However, if the consumer had low levels of self-esteem, marketing to the ideal self was more effective. Therefore, focusing on positive emotion words, phrases, and images consistent with the ideal self may be more attractive to consumers. For MFTs, ensuring positivity in emotional marketing can provide encouragement and hope that things can improve

(Dembo & Clemens, 2013). It would be useful to determine the extent to which MFTs are positive in the websites, marketing to actual or ideal selves in an effort to create a positive and trusting emotional tone.

Therapist Marketing

In addition to learning to appropriately brand, there have been a few studies regarding ideas for improving therapy marketing practices. There are a few studies with ideas and personal accounts for what could be helpful for marketing therapy. For example, Colburn (2013) provided MFT WEBSITES 13 ideas for diversifying a counseling practice to attract more and varied clients, such as providing the opportunity for long distance therapy. Others have delivered thoughts on advertising in specific geographic locations, like within a rural community (Cohn & Hastings, 2013).

Additionally, Gilchrist and Stringer (1992) provided counsel of “do’s and don’ts” for advertising, pulling their ideas from other non-marketing researched topics, such as client perceptions.

Furthermore, there has been discussion surrounding the ethics of marketing in order to maintain and project uprightness and honesty as a therapist (Knapp & VandeCreek, 2008). Neither of these conducted studies with samples, but each are useful in getting the conversation started for building awareness of clinical counseling resources and establishing a practice or agency.

Conclusion

Research has clearly established the efficacy of mental health care. The field of Marriage and Family Therapy is strong and continues to move forward in positive directions that have the potential to provide many worthwhile outcomes. Yet, little is known regarding therapy marketing practices. More research is required to strengthen our understanding of how therapists reach out to potential clients through various marketing efforts. By understanding trends in passive marketing through an examination of therapist websites, clinicians can better understand what information individuals interact with before becoming clients. An understanding of what potential clients interact with may enable therapists to improve their marketing practices to create a strong, positive, and inspiring brand image through their marketing strategies.

Appropriate advertising can have the capacity to remove stereotypes and stigmas (Brown, 2017), increase mental health and therapy awareness, and promote therapy attendance (Chaturvedi,

2016; Johnston, 1998; Lannin et al, 2017; Tentoni, 1997). Clients will be able to make better MFT WEBSITES 14 informed decisions that will lead them to the desired treatment, and to positive outcomes for individuals, couples, and families.

Purpose of the Study

The purpose of this study is to explore and identify trends in how marriage and family therapists (MFT) are passively marketing themselves online through websites. By exploring the content of MFT websites, the researcher will be able to determine the emotional tone of the sites and develop themes that capture the content of the sites. Examining therapist websites is a foundational step in understanding therapy initiation processes. Additionally, a better understanding of MFT websites could lead to better marketing of services to those seeking help, and a strengthening of brand image through better marketing. Research is deficient in this topic area and greater understanding of trends in passive marketing is a useful first step in developing sound client engagement strategies to reach out to individuals most in need. Due to the exploratory nature of this study, the following general questions helped guide the research:

1. What services and specialties do MFTs market to potential clients, and to what

populations do they market?

2. How do MFTs make use of written text, photos, and the organization of their website to

market to potential clients?

3. How do MFTs describe their training and approach to therapy as well as their personal

and professional self?

4. How is the field of Marriage and Family Therapy described and promoted through

written text on therapist websites?

5. How do MFTs differentiate themselves from other counseling degrees and/or fields?

MFT WEBSITES 15

CHAPTER 3: METHODOLOGY

Therapy effectively assists people with a variety of challenges (Duberstein et al., 2018;

Smith & Grawe, 2003). It is important to consider how therapists are reaching out to potential clients in order for them to enter into and subsequently benefit from therapy services. However, there is a lack of research regarding marketing practices of marriage and family therapists

(MFTs). Moreover, many therapists are passively marketing online via websites. Even less is known about the strategies utilized for passive marketing practices via websites, or about the utility of that practice. Learning more about what therapists are doing to reach out to potential clients can assist therapists in improving their marketing practices as well as assisting potential clients through the therapy initiation process. It would also assist the field to know if it is even worth paying for an online listing, or if websites are worth the time and effort to market therapy services. Additionally, it is not understood what therapists are doing to describe their professional field. Understanding how therapists are depicting or branding MFT can help define and distinguish MFT from other counseling fields. The present study examined MFT websites in order to better understand MFT branding, therapist marketing practices, and ultimately assist potential clients to receive appropriate therapy services. The current chapter describes the methodological approach used to meet the goals of this study.

Design

This study was qualitative. The focus was on investigating what and how MFTs are passively marketing their services through their websites. A qualitative content analysis design appropriately served this purpose by creating codes and ultimately themes that described MFT passive marketing practices as seen. Additionally, tabulations were made by using a software program that assisted in the examination of the website information and provided insightful MFT WEBSITES 16 statistics that enhanced the essence and meaning of the data, bolstering the content analysis. The qualitative content analysis allowed me to examine content, identify differences and commonalities among MFT website designs, code for categories and themes, as well as quantify the breadth and depth of said themes. Furthermore, the qualitative content analysis helped determine what exactly was occurring on MFT websites in order to establish a foundation of

MFT marketing practices.

Content analysis is a means of examining and interpreting textual and visual data (Cole,

1988). Content analysis is an adaptable method that can be used in qualitative and quantitative designs as well as for a variety of problems and questions (White & Marsh, 2006). Furthermore, content analysis can be approached deductively and inductively (Elo & Kyngäs, 2007). Because of the lack of information and literature surrounding MFT websites from which to test previous theories or ideas, an inductive content analysis was used for this study. Meaning, that from the codes and themes, concepts and ideas emerged to describe the phenomena (Thomas, 2006). The inductive content analysis approach supported and included the use of open coding (Elo &

Kyngäs, 2007), which occurred in this study. Content analysis offered a systematic approach to discovering the structural features of MFT websites as well as a means to extrapolate conclusions regarding how the verbal and visual information from the websites passively marketed psychotherapy services to potential clients.

I also made some tabulations via the sampling method and a corpus data linguistic software program to conduct a textual analysis and obtain a sense of the data as a whole. Textual analyses help to determine the nature, quality, and feel of textual data (Loughran & McDonald,

2011). Additionally, textual analyses provide a means of discovering the cultural and contextual meaning of data (Fürsich, 2009). The software program I used for this study, analyzes and MFT WEBSITES 17 classifies textual data based on pre-created categories (Francis & Booth, 2001). The numbers added meaning to the data with regard to the people creating websites as well as enhancing the categorization of the textual data. First, from the sampling process I was able to create two documents: one for therapists that had a website and one for therapists that did not. Second, the software program, Linguistic Inquire Word Count (LIWC; Francis & Booth, 1993; Pennebaker,

Francis, & Booth, 2001), was used to assist the coding process and quantify the textual data. The

LIWC program provides statistical information for any given text. In addition to counting words, identifying pronouns, and highlighting punctuation and other grammatical categories, the LIWC can recognize and calculate word usage and type from pre-established categories. Some of the categories include positive and negative emotion words as well as social constructs. Words like kindness, happy, and nice would be categorized under the positive emotion category.

Furthermore, the numerical score produced from the analysis for a given category represents a percentage of the total word count of the uploaded document.

In addition to pre-established categories, the LIWC also has four summative dimensions: analytical thinking, clout, authenticity, and emotional tone (Pennebaker et al., 2001). The four summative dimension scores are standardized on a scale from zero to 100, and they are a representation for the entire uploaded document. For authenticity, a higher number indicates greater authenticity, more humility, and being more personable. For clout, a higher score is indicative of confidence, leadership, and social status. Higher analytical thinking scores indicate higher formal and logical thinking. Lastly, a higher emotional score indicates an overall positive emotional tone for the text. The LIWC program provides a means of identifying what words are selected and into which category. However, the LIWC program does not show how the categorization occurs for the summative dimensions. MFT WEBSITES 18

The LIWC has been deemed a valid program (Kahn, Tobin, Massey, & Anderson, 2007) that can appropriately and accurately quantify and categorize textual data. The LIWC has been used in textual analysis studies to measure verbal emotional expression from biographies (Kahn et al., 2007), determine deceit from participant stories (Newman, Pennebaker, Berry, & Richards,

2003), and determine vernacular differences between various groups (Stirman & Pennebaker,

2001). Furthermore, the LIWC has been used in different fields of study, such as psychology

(Pennebaker & Chung, 2007), social conduct (Mehl & Pennebaker, 2003), and psychopathology

(Rude, Gortner, & Pennebaker, 2004).

In comparison to another linguistic program, Psychiatric Content Analysis and Diagnosis

(PCAD; Gottschalk & Bechtel, 2007), the LIWC was deemed the more effective software program to quickly and accurately analyze emotions in text (Bantum & Owen, 2009).

Additionally, the LIWC has been adapted and corroborated for the Chinese language (Huang et al., 2012). The LIWC software was used as a means to enhance the meaning of the data found from the content analysis. Additionally, the LIWC helped guide the research process. By providing statistics on the pre-established categories, I obtained greater understanding of the data and guidance for things to consider while analyzing and coding.

Website Definition

Because I examined MFT websites as the principle source of data, and there are many different forms and types of websites found on the internet, it is prudent that I provide a definition and description of what type of websites I selected and analyzed. For this study, I defined an MFT website as an online domain that was created specifically for and by one therapist to communicate and present information and services pertaining to their personal therapy practice. Furthermore, each website had to have its own URL address that was not MFT WEBSITES 19 related to another company or search engine. It was important that the website was not related to another company or search engine in order to create a more consistent group of websites that could be compared and analyzed in a meaningful and related manner as well as remove differences not fitting with the frame of this study. Thus, excluded from this definition, and thereby this study, would include the following: write-ups on Psychology Today, group or shared practices, community agency pages that have a write-up of individual therapists, blogs, Facebook pages or other social media accounts dedicated to advertising therapy services, or any other form of online material that was inconsistent with the aforementioned definition.

Sampling

In order to locate the websites, this study made use of one popular search engine:

Psychology Today. This domain contained information regarding the therapist field/discipline

(MFT, Social Work, Professional Counselor, etc.) and specialty. Therapist Locator is also a familiar site for locating a therapist and is associated with the American Association of Marriage and Family Therapy (AAMFT). However, after exploration of this site it was found to be less likely to provide a link for the MFTs professional website. The lack of a link seemed to be due to either the setup of the site or the therapist choosing not to place the link on the site. However, therapists consistently seemed to have a link to their professional website on Psychology Today.

Therefore, this study solely used Psychology Today.

Data was collected from MFT websites across the United States (U.S.). According to the therapist search engine on Psychology Today (Psychology Today, 2019), there are 39 cities across the U.S. that are prominent locations for finding MFTs. Meaning, a large number of

MFTs are employed in these locations. To increase representativeness, I selected five major cities from this list in order to reflect the major regions of the U.S. These included: Seattle MFT WEBSITES 20

(West), Austin (Southwest), Chicago (Midwest), Atlanta (Southeast), and Boston (Northeast). I included twenty-five websites in the analysis. Twenty-five websites proved to be an appropriate sample size in order to reach theoretical saturation, where data being gathered was no longer yielding new information (Charmaz, 2008). Concrete understanding of the MFT websites was obtained from this sample. Furthermore, this sample size was comparable to Mason’s (2010) review of sample sizes in qualitative studies. He discovered a typical sample size for qualitative studies contained about thirty-one participants.

To search for the MFT websites, I accessed Find a Therapist in the Psychology Today website. Find a Therapist provided a search bar that requested a city name or a zip code. I entered the major city into the search bar and names of therapists appeared below in groups of twenty per page. After the initial entering of the city name, a list of categories on the left side of the page appeared along with the therapist names that offered a means of refining the search. The categories included: types of insurance (e.g. United Health or Cigna), issues treated (e.g. anxiety or depression), sexuality (bisexual, gay, or lesbian), gender (to show only male or female therapists), population treated (e.g. children, adults, elderly, etc.), language spoken (e.g. Spanish,

Korean, or Hindi), faith (e.g. Christian, Hindu, or Islam), types of therapy provided (e.g.

Cognitive Behavioral Therapy, family/marital, or EMDR), and an option for online counseling. I only refined the search in the types of therapy category by selecting family/marital in order to increase the likelihood of finding MFTs. The other categories bore no influence towards hindering this objective and were not used. However, many of the options within the categories were found on the individual MFT websites (e.g. languages spoken or populations treated) and as appropriate, I placed them in the Microsoft excel spreadsheet during the analysis process. MFT WEBSITES 21

After refining the search, I proceeded to scroll down the list of names offered on

Psychology Today that appeared in a column underneath the search bar.

MFT WEBSITES 22

Many stated their credentials (e.g. LMFT, LCSW, etc.) next to their name in the initial search list, which greatly assisted the sampling process. However, many did not and I would select the therapist’s name to see if I could find the credentials on the next page that contained a write-up of the therapist and their services.

If I still could not find the credentials I would click on the therapist’s website (if provided) and quickly search their website to determine if they were eligible to participate in the study. Typically, the therapist’s credentials could be found on the Home page, About Me page, or the Contact page. Thus, I clicked on those tabs to find this information. Additionally, when I had found an MFT, I would click on their name to verify whether they had a website link on the write-up page. In a Microsoft excel spreadsheet I entered the participant’s name, a ‘Y’ (yes) or

‘N’ (no) for whether they had a website or not, a copy of their web address, and their credentials.

The described process continued until I had obtained the desired sample number.

I limited the pool of potential websites by focusing strictly on MFT websites, as a major purpose of this study was to increase understanding regarding how MFTs are marketing to MFT WEBSITES 23 potential clients. There is a paucity of research on MFT marketing, and learning how they are passively marketing online will lead to greater marketing practices and assist in reaching out to those in need of therapy services. Additionally, I only accepted MFT websites where the therapist was a licensed Marriage and Family Therapist (LMFT) and that involved only one clinician for the site. Thus, websites that advertised a group practice or community agency were excluded from this study. A few websites had links or pages that connected to a blog or social media account. Nevertheless, these were kept in the study because those were additional features rather than the primary purpose of the website.

With the exception of Boston, I selected 100 MFT names from each city. I entered the name of the major city into the search bar and selected the first 100 MFT names to populate in the results. Because some cities like Chicago, Atlanta, and Boston, did not yield 100 MFT names with the searching of the major city name, I expanded the search to include other cities and towns that were still considered part of the greater metropolitan area. For example, the greater

Chicago area includes cities and towns as far west as DeKalb and La Salle counties. However, even after this expansion I was only able to obtain fifty-five MFT names from Boston. Though this was inconsistent with my desire to obtain 100 MFT names from each city, it made sense that

Boston would yield fewer results when comparing its geographical and urban size with the other four major cities. Furthermore, from the fifty-five MFT names, I was able to obtain enough participants that met the criteria of having a website. Finally, I gathered and entered each cities’ sample into their own Microsoft excel spreadsheet. Thus, a total of 455 MFT names were gathered and numbered in the Microsoft excel sheets.

Next, I sifted through and reduced the list of participants based on whether or not they had a website. From my exploration of the therapist search engine, I discovered that there were a MFT WEBSITES 24 number of therapists who did not have a website (or at least a link on Psychology Today to access a personal website) for their therapy practice. Though these therapists were not examined for the study’s main purposes, information was gathered regarding how many do not have a website. For each city, I created separate Microsoft excel spreadsheets for MFTs that had a website and for MFTs that did not. For Atlanta, sixty-six of the 100 MFT names had a website.

For Austin, eighty of the 100 MFTs had a website. For Boston, which only had fifty-five names, twenty MFTs had a website. Of the 100 MFT names in Chicago, fifty-seven had a website.

Lastly, for Seattle, eighty-seven of the 100 names had a website.

After this separation process, I used random sampling to select twenty-five MFT websites. Within the Microsoft excel document, I created random numbers for each of the MFTs that had a website. The numbers were randomly assigned and provided to the MFTs by

Microsoft Excel and did not appear in any numerical order. I then had the Microsoft excel sheet sort the numbers from smallest to largest, which randomized the sample. Finally, I selected the first five names generated by this process. This was repeated for each of the five cities.

Occasionally, a randomly sampled participant would not meet criteria for participation (e.g. being part of a group practice or the website was written in a language I could not read). When this occurred, I removed the participant from the sample and went to the next name in the randomized Microsoft excel list.

Many of the final sample had additional licenses or credentials reported, with totals of each as follows: Five Licensed Professional Counselors (LPC), three Certified Sex Therapists

(CST), one Licensed Clinical Social Worker (LCSW), one Internationally Certified Advanced

Alcohol and Drug Counselor (ICAADC), one Doctor of Philosophy (Ph.D.), one Juris Doctorate

(J.D.), one Certified Clinical and Advanced Clinical Hypnotherapist (CCACH), one certified in MFT WEBSITES 25

Trauma Center Trauma Sensitive Yoga (TCTSY), one Certified Yoga Teacher (CYT), one

Licensed Mental Health Counselor (LMHC), one Certified Professional Counselor (CPC), one

Master Addiction Counselor (MAC), and one Counselor of Mental Health Services (CMHS).

Furthermore, though the data contained information regarding real human therapists, the names and material published on the websites are public information. Thus, Institutional Review Board

(IRB) approval was not necessitated for this study, as data were non-human in nature.

Psychology Today.

Psychology Today is a website that provides information surrounding topics related to psychology, mental health, and counseling (Psychology Today, 2019). One can access, news, trending topics, take self-tests, and subscribe to their magazine (Psychology Today, 2019).

However, one of the more useful and prominent features of the website is the capacity to locate a therapist (Psychology Today, 2019). By simply entering a city or zip code one can find a large variety (dependent on location) of therapist names (with their photo) from which to choose.

Furthermore, one seeking therapy services can refine the search by type of insurance accepted, issues and populations seen and treated, type of therapy offered, etc. (Psychology Today, 2019).

Though the type and length of information provided varies for each therapist, upon clicking on a therapist name one is typically directed to a new page with details concerning the therapists experience, specialty, professional license, as well as insurances accepted and client fee. Additionally, the therapist’s email and phone number are provided and can be accessed directly from the site as well as a link to the therapist’s own professional website. In fact,

Psychology Today (2019) advertises to professional therapists that the Psychology Today website/search engine takes away the need to create one’s own website. MFT WEBSITES 26

In order to be listed on Psychology Today therapists must sign up online, pay a monthly fee of $29.95, and provide the necessary write-up regarding themselves and their services. This write up includes a professional statement, the services and specialties provided, and options to attach photos (Psychology Today, 2019). Though not advertised as a requirement, many of the therapists using the Psychology Today’s services have their own website that is linked on their

Psychology Today write up page. Furthermore, Psychology Today personally verifies each therapists license number to ensure legitimacy of the professional using their marketing services

(Psychology Today, 2019). The verification helps maintain trust among the professionals using the site as well as the confidence of the potential clients seeking services via this search engine

(Psychology Today, 2019). Upon being verified, Psychology Today provides the registered therapist the ability to track how many people view their profile on Psychology Today as well as how many called or emailed from said profile. Furthermore, the therapists become a member of a professional community for insight and discussion, they are provided access to the site’s magazine, and are promised increased exposure for their profile (Psychology Today, 2019).

Psychology Today (2019) reports that about forty million people visit their site each month. They have over 100,000 therapists and other professionals using their services and about three million people subscribing to their magazine. Additionally, they promise that registering with Psychology Today will increase likelihood of being found via other search domains like

Google or Bing (Psychology Today, 2019). Thus, Psychology Today appears to be a popular service used frequently by both professionals and potential clients, making it an appropriate domain to use for this study.

MFT WEBSITES 27

Procedure & Analysis

Procedure and analysis often occur concurrently within qualitative designs. Even during the sampling process analysis had begun. After selecting the MFT sample, each individual website was organized and analyzed in its own Microsoft excel spreadsheet. I used the spreadsheets to discover and organize the information that MFTs were putting on their websites to market to clients and/or potential clients. The spreadsheet became a matrix that contained labeled rows and columns that matched the information to the appropriate category. The information categorized in these matrices helped dictate the results. The matrices acted not only as a means of organization, but provided a method for exploring and analyzing the data.

Categorizing the data in this manner made for easy access, retrieval, and efficiency for tabulating and coding. The matrices supplied the information that also guided the coding process. The row labels consisted of the names of the website pages, such as: Home page, My Approach page,

About Me page, Services page, etc. The columns were labeled after unique categories that came from an initial overview of the websites and included the following: 1) Therapist Name, Web

Address, Site Domain, Contact Information, 2) Images/Photos, 3) Services & Specialties, 4)

Education/Training & Credentials/Experiences, 5) Quotes & Testimonials, 6) Insurance & Fees,

7) Background Theme & Font Type, 8) Description of MFT, 9) Description of Therapy, 10)

Description of Therapist, and 11) Links & Forms. Furthermore, this organization and formatting commenced the beginning stages of analysis as I highlighted components of MFT websites that seemed prominent and significant.

Using this matrix, I examined the website and each of its pages, read through the text, identified photos/images and other data, and matched the information to the appropriate cell.

Thus, information about therapy services found on the Home page was placed in the appropriate MFT WEBSITES 28 cell that matched the column and row on the spreadsheet. The content analysis process helped to establish a strong foundation for what was actually being placed and portrayed on MFT websites.

Certainly, online content analysis does have some challenges, with one being the potential for online sites to change their information or material (Kim & Kuljis, 2010). Two methods were suggested to avoid this issue. First, I quickly collected the necessary data (Koehler, 1999).

Second, downloading and saving the website in its complete form prevented potential loss of the original examined data (McMillan, 2000). I did this by saving the website as a pdf document.

Saving the websites became particularly relevant for the photos and images that the MFTs portrayed on their websites and could potentially remove or change. Therefore, in order to avoid loss or confusion with the data, I followed these two ideas. I downloaded and saved each of the websites to their own folder. I also downloaded the images from the websites and placed them in the folder with the corresponding website. Additionally, I quickly examined the websites to allocate the appropriate information into the Microsoft excel matrices.

Finally, upon completing the matrices for each website, time was spent examining the data across each MFT website matrix. I looked for trends and patterns that appeared across the websites. I systematically reviewed the matrices multiple times. Furthermore, I searched for idiosyncratic differences that existed. To do this, I highlighted words in each matrix column that provided descriptive meaning to the category. I counted the number of cells for each row and column in which information was provided. I identified categories that were deficient in information or contained large amounts of data. Additionally, I counted words in certain columns

(e.g. services provided) to determine patterns and differences across MFT websites. I also examined the website vernacular that could influence the open coding process. The analysis MFT WEBSITES 29 process improved the subsequent steps in the research study by organizing the data into categories and providing initial codes.

LIWC.

Prior to commencing analysis via coding, I uploaded the website data into the LIWC software program. Because the LIWC produces statistical information surrounding categories such as emotions, authenticity, social processes, etc., it seemed prudent to analyze these areas before coding. Using the LIWC provided insights that guided the analysis process, provided areas in which to search and examine, and assisted in the creation of codes. Performing this analysis influenced my coding process, which could inherently produce positive and negative consequences. For example, it could take away from the natural process of coding that occurs without computer software assistance and thereby, bias my categorization. However, this data corpus tool does not create codes or categories. Rather, it can point out whether an MFT’s tone is negative or positive, or if the text suggests a social focus. As the researcher, I used these results as a guide that enhanced my ability to capture the meaning of the data. Additionally, word counts often point out ideas that should be of greater concern (Stemler, 2001).

Thus, I copied and pasted the data from each website into three separate word documents that contained information from the Home page, About Me page, and My Approach page. The three website pages provided information that was most pertinent to the purpose of the study, and therefore, became the focus of attention for coding and the LIWC. Analyzing each website individually allowed for comparisons across MFTs. Similarly, I created a city document for each of the pages, that was an aggregate of all the websites for each individual city. I also created another document that was an aggregate of all the websites in the entire sample, again for the three different pages. The document provided an overall conceptualization of what MFTs do as a MFT WEBSITES 30 systemic whole. Each of the documents were uploaded into the LIWC software program and results were provided.

Coding.

Next, more in-depth coding occurred in order to further identify potential patterns and themes in the data. First, I made use of the qualitative software Dedoose (Dedoose Software,

2014). This program allowed me to more quickly, conveniently, and effectively organize data, create codes and sub-codes, as well as identify emerging patterns. For each participant, I uploaded a Word document of the website data into the Dedoose program. For these documents,

I combined the three Word documents (Home page, About Me page, and My Approach page) used in the LIWC into one individual document for each website. I read through all of the websites multiple times in order to familiarize myself with the data. Additionally, while coding, I opened the actual website to capture and maintain the true nature of the data. While I was reading and reviewing, I began Saldaña’s (2015) process of first cycle coding. This involved a method similar to opening coding (Elo & Kyngäs, 2007; Vaismoradi, Turunen, & Bondas, 2013) where I assigned initials codes that captured and described the meaning of the data. A mixture of

Emotion, Descriptive, and In Vivo coding (Miles Huberman, & Saldaña, 2014) were used to label the data. Descriptive coding was a means of providing a word or phrase to summarize the message being communicated in a given piece of data. Similarly, Emotion coding provided a descriptive word or phrase that captured the feelings observed (Miles et al., 2014). Finally, In

Vivo coding honored the language used by the therapists on their websites (Miles et al., 2014) by creating codes that were worded directly from the data.

For this study, it was important to understand the message that the MFTs were trying to convey. Initially, I thought to categorize the data by idea statements. Meaning, I would provide a MFT WEBSITES 31 category to the idea being expressed by the therapist, which could include multiple sentences or a whole paragraph to one category as opposed to each line having its own theme. However, upon starting the coding process I discovered that the therapists were conveying multiple ideas in just one or two sentences. Thus, my coding changed to resemble a line by line coding process in order to reflect the information communicated in the website. Additionally, there were numerous times when I assigned more than one code to a sentence. This study sought to explore and understand what MFTs were portraying and communicating on their websites, and thereby, the categories created were influenced and driven by the data. Furthermore, this coding process occurred for each of the websites and required an iterative process of reviewing and re-reviewing each data sheet until I deemed that the data had been sufficiently categorized. The coded data was then organized into like categories, matching codes that were related to each other.

After the first cycle of coding, I commenced another round of analysis that Saldaña

(2015) named second cycle coding. The codes created from the first cycle were clumped together into similar categories to create pattern codes (Miles et al., 2014). Pattern codes are qualitative analytical inferences about the data that assist in describing phenomena (Miles et al., 2014).

Code words or phrases used frequently and common themes were identified and assisted with describing the patterns occurring across the MFT websites (Miles et al., 2014).

Therefore, I determined what codes related and how they related to each other based on the data themes. I printed all of the open codes and systematically reviewed all of them multiple times. I used different colors to mark and indicate similar codes. Once the open codes were highlighted, the similar codes were clumped together. This occurred for all the codes until a smaller number of categories existed. Additionally, I reviewed the newly combined similar groups to ensure the codes matched and fit in the grouping. Next, I determined a pattern code MFT WEBSITES 32 that classified the commonality that existed amongst each of the new clusters (Miles et al., 2014).

The pattern codes provided the description of the phenomenon that was occurring on the MFT websites.

Jottings and Memoing.

Two important components of qualitative analysis are the use of jottings and memoing

(Miles et al., 2014). Jottings provided me the opportunity to quickly make notes or comments regarding any insights, feelings, reactions, etc. that I had during the data collection and analysis process. They served as quick reminders for in the moment thoughts and ideas I had while examining the data (Miles et al., 2014). As I gathered and examined the MFT websites, jotting was invaluable by helping me be aware of my assumptions and biases as well as assisting me in the critical thinking and analysis process. I made these jottings via comments in a Microsoft

Word document that I kept open while analyzing the data and that I dated so as to remind myself of the meaning of the jottings. Furthermore, this organized my thoughts and allowed for quick retrieval of my ideas.

Memoing also provided another means for analysis and higher-level thinking. Memoing took jotting to a more significant and meaningful level by processing my thoughts, reflections, and ideas that came about during the data gathering and analysis process (Miles et al., 2014). The process of memoing allowed me to think about my relationship to the data, how it was relating to the research questions, and provided moments to conceptualize the current methodological process (Miles et al., 2014). Additionally, memoing offered the opportunity to examine and discover relationships and connections among the data and codes (Miles et al., 2014). I used memoing to refine my thinking, improve the analysis, and ultimately obtain greater results and meaning from the data. MFT WEBSITES 33

Reflexivity

A fundamental component of qualitative research is reflexivity. Reflexivity was a means in which I reflected on how my worldview and personal experiences influenced and interacted with the data collection and analysis process (Creswell, 2014). Furthermore, reflexivity called attention to how my background could influence the creation of themes and codes, and thereby, the study’s outcome (Creswell, 2014). Consistently staying aware of my thoughts and feelings towards and about the research was crucial. This goes beyond trying to remove one’s biases and assumptions, but to actually understanding how they are related to the conception of the analysis results (Creswell, 2014). This occurred concurrently with analysis and after a session of research activities (Mauthner & Doucet, 2003). Furthermore, reflexivity has been compared to the internal dialogue that clinicians have when working with clients (Berger, 2015).

I recognize that I am a new professional in the MFT field. Undoubtedly, my passion, training, and excitement for the MFT field drives a lot of my thinking and focus. Therefore, I made use of jottings and memoing to help me with reflexivity. These types of activities assisted my self-reflection and allowed me to involve myself with and differentiate myself from the data.

Gratefully, I am a trained clinician in Marriage and Family Therapy and have done self-of-the- therapist (Rober, 1999) work to which Berger (2015) inferred. I have explored and continue to reflect on my beliefs, culture, opinions, and experiences and how they influence my work as a therapist. I believe my training and experience in this area helped me during this research study.

Nevertheless, I consistently sought to be mindful of reflexivity throughout the entire research process.

MFT WEBSITES 34

CHAPTER 4: RESULTS

It is crucial for researchers and clinicians alike to understand how therapists reach out to potential clients and assist them through the therapy initiation process through marketing efforts.

People have greatly benefitted from therapy services (Duberstein et al., 2018), yet little is known regarding how clients entered therapy, and even less is known concerning therapist marketing strategies to assist in the initiation process. Learning more about Marriage and Family

Therapists’ (MFTs) websites would provide valuable information regarding the current practices employed by MFTs in their passive marketing practices. With more data, it is possible to develop suggestions to improve therapy marketing practices, and, by extension, increase the likelihood that clients engage in services. Billions of people are using the internet (Internet World Stats,

2019) and many are using online services to seek help (PewResearch, 2009). Websites can have a strong influence on online customer consumption (Bačik & Fedorko, 2016). Unfortunately, a lack of research regarding MFT passive marketing, particularly via websites, makes it difficult to make concrete suggestions. The present study offers a first step in developing marketing best practices – a qualitative inquiry into content, emotional tone, and visual imagery in MFT websites.

MFT websites were examined to determine what and how MFTs market themselves and their services to potential clients and the communities they serve. The present study was a qualitative study that used a content analysis framework to identify the phenomena of MFT marketing via websites. Because of the qualitative design, the researcher will use first person when referring to research conducted. This design helped to answer questions regarding what and how MFTs market to potential clients. Additionally, I sought to understand how MFTs describe themselves and their field. To assist this, I used matrices to organize and examine the MFT WEBSITES 35 website data across five United States (U.S.) cities: Atlanta, Austin, Boston, Chicago, and

Seattle. The use of matrices helped identify initial codes and themes. Additionally, this study made use of the Linguistic Inquire Word Count (LIWC), which is a textual analysis software program that counts and categorizes words (Francis & Booth, 1993; Pennebaker et al., 2001).

The LIWC supported the study by highlighting potential areas for examination and by providing information about the emotional tone and authenticity of the textual data. Next, open coding was used for three main pages within each of the MFT websites. Coding was conducted with the data management assistance of the online qualitative program called Dedoose (Dedoose Software,

2014). Using Dedoose helped with creating codes that captured the meaning of the idea being communicated. Finally, a third round of coding occurred in which the initial codes were clumped into categories of similarity and a pattern code or theme was created to capture the meaning of the various categories. The current chapter presents the results of the analyses.

Matrices

It was important to develop a means of organizing, counting, and making sense of the website data. To assist with making sense of the data and to help answer the research questions regarding what services and specialties MFTs market and to whom as well as how they make use of written text, photos, and the organization of the website to market themselves, Microsoft

Excel spreadsheets were used to create two-dimensional matrices. The matrices assisted with the organization and analysis of the MFT website content. The columns were labeled and consisted of the following categories: 1) Therapist Name, Web Address, Site Domain, Contact

Information, 2) Images/Photos, 3) Services & Specialties, 4) Education/Training &

Credentials/Experiences, 5) Quotes, 6) Insurance & Fees, 7) Background Theme & Font Type, 8)

Description of MFT, 9) Description of Therapy, 10) Description of Therapist, and 11) Links & MFT WEBSITES 36

Forms. The columns were created after an initial overview of the websites to classify data commonly displayed on the websites. The rows were labeled after the names of the website pages, such as: Home page, My Approach page, About Me page, and Services page.

I made tabulations for the number of filled cells within each row and within each column.

The tabulations helped to identify where most of the data was on the websites as well as to observe places where data was missing. Examining the matrices of the rows for the whole sample, and excluding the Background Theme & Font category, showed that the Home page contained the most cells, representing information for thirteen websites. The number seems to indicate that the Home page is an important location to communicate to potential clients. The

Home page was followed by the About Me page (eight websites), Approach page (five websites), and the FAQs page (four websites). The number of filled cells indicated that most of the information being communicated by the therapists was displayed on these four pages. With regard to the columns, the category with the most filled cells was Images/Photos (fourteen websites). Images/Photos were followed by Description of Therapy (seven websites), Links &

Forms (seven websites), and Services and Specialties (four websites). Additionally, for the columns, the categories with the least amount of filled cells were the Description of MFT

(twenty-four websites), Quotes & Testimonials (twenty-three websites), and Insurance & Fees

(twenty-two websites). Finally, nine of the twenty-five websites did not have any filled cells for the Description of MFT. The finding of MFT websites having nine of twenty-five websites without an MFT description indicates that therapists place a low priority on specifically describing their services as an MFT.

MFT WEBSITES 37

Photos

Most of the MFT websites had photos or images displayed on the various pages.

Frequently, these photos seemed to match the theme or message being communicated by the text.

For example, when a therapist wrote about couples therapy an image of a couple holding hands, or similar image, was displayed. I downloaded and saved the photos from each of the websites.

The photos were easily accessed, and did not require permission to use, as they were publicly available.

There were four general types of photos: 1) headshot-style photos of the therapist; 2) nature/environment photos; 3) live action stills; and 4) photos of the therapy room and/or building.

Headshots. Every website displayed a therapist photo, which typically was found on either the Home page, About Me page, or both. Analysis of the trends suggested the following things were common among photos. Most photos were a headshot of the therapist or started from the chest up. A majority of the therapists were smiling with teeth showing, and dressed in business attire. Therapists held a variety of body postures and were posted in a wide range of settings.

Though rare, there were also a few that provided pictures of their partner or family members:

MFT WEBSITES 38

Additionally, there were some websites that provided multiple pictures of the therapist and in different stances or postures:

The photos also seemed to be an opportunity to demonstrate one’s personality:

MFT WEBSITES 39

Nature/Environment. Many websites featured photos or images that represented nature.

These consisted of a wide array of scenic settings. Many included photos of flowers and trees:

Others included birds, boats, or images of the ocean or lake:

These images seemed to serve the purpose of instilling hope, suggesting inner beauty, or to simply provide pleasing background to the website. Either way, these images and photos were commonly seen on the MFT websites.

Live action stills. The live action still photos contained people that appeared to exhibit a behavior or emotion consistent with the theme of the current webpage. This photo was a reiteration to the observer that this therapist worked with families to achieve happiness and connection:

MFT WEBSITES 40

This photo was suggestive of a variety of feelings, such as feeling overwhelmed, sad, or despair, and was placed adjacent to the list of reasons why someone may attend individual therapy:

This photo was indicative of the therapy services for couples:

MFT WEBSITES 41

Therapy room and building. The last group of photos were of the building and/or room where therapy occurs. These were less common, but seemed to be a means of providing greater understanding of where therapy would be and what the room or clinic would physically look like:

Finally, it is worth noting that two therapists provided embedded YouTube videos of themselves. They provided information regarding their therapy services. These data were outside of the scope of this study, but undoubtedly have their own impact on marketing to clients and potential clients. MFT WEBSITES 42

Overall, the photos seemed to be a means of enhancing the website and therapist marketing strategy. They allowed one to get a glimpse of the therapist and their personality.

They assisted with reinforcing the message or topic being discussed. Last, the photos were a means of communicating emotion.

LIWC

The software program, Linguistic Inquire Word Count (LIWC; Pennebaker et al., 2015), was used to assist with the content analysis process by counting words and providing numerical representations of several aspects of language use. The aspects of language use included things like emotional tone, analytical nature, confidence, and trustworthiness. The aspects of language that are available to count are pre-determined by the software program. The LIWC provided numbers that described things of interest.

Textual data from three website pages were selected for inclusion in the LIWC analysis:

Home page, About Me page, and Approach page. These three pages were selected based on the likelihood of the potential client clicking on them. The Home page was the first part of the site that the potential client would be likely to see, and this would have an immediate influence on their thoughts and feelings regarding the therapist. The About Me page also provided more insight into what the therapist would be like and whether they seemed like a good fit for the potential client. In addition, most websites included About Me pages. The Approach page provided information regarding content addressed and processes that would occur in the therapy session. Moreover, the Approach page was of interest due to the likelihood of explaining the field or approach typical of MFTs. Additionally, these pages yielded significant information that related to the research questions of understanding how MFTs market themselves and describe their therapy. The textual data from the website pages were copied and pasted into their own MFT WEBSITES 43

Word document and analyzed individually. Thus, there were three individual documents per website. Not every website labeled their pages with these exact names. However, I chose these labels to generalize to all webpages that contained similar content. For example, if the therapist had labeled a page “how therapy works”, it was categorized as Approach.

I created a Microsoft Word document that contained the Home page information for each participant in each city. Thus, the five websites, that were randomly sampled from the list of all

MFTs that had a website, selected from Chicago were clumped together into one document with information from the Home pages. The combining of each city’s websites into one document also occurred for the About Me pages and the Approach pages. Furthermore, I combined the entire sample website Home pages into a single document as well as individually combined sample documents for About Me and Approach pages. I used the LIWC program to analyze each of the aforementioned documents because I was interested in overall counts and per-city counts in order to look at differences in cities and not just the overall whole. Additionally, all three pages were combined into one document for each city as well as for entire sample to receive an overall analysis of the websites. Here, I provide the results for the combined three pages of the whole sample, and the overall sample document for each individual webpage: Home, About Me, and Approach. Then for each city, I provided tables for the four main summary results of the combined three pages as well as the totals of the individual pages.

Overall Sample Combined.

The analysis of the combined pages of Home, About Me, and Approach for the whole sample produced a total word count of 31,620 words. One full page of single space typing in a

Microsoft word document can contain around 400 to 600 words. Altogether, the sample was approximately 88 pages of text. The LIWC has four summary categories that were developed MFT WEBSITES 44 with the most recent software. The categories are standardized with scores on a scale of zero to

100, and they include the following: analytical thinking, clout, authenticity, and emotional tone.

For analytical thinking, higher numbers suggest a person used a higher level of logical thinking

(Pennebaker, Booth, Boyd, & Francis, 2015). Lower numbers suggest a person used more narrative or personal language (Pennebaker et al., 2015). The category clout referred to one’s confidence, social status, and leadership (Pennebaker et al., 2015), with higher numbers indicating more of those attributes. Authenticity considered how humble, personable, and vulnerable a person was, with high numbers suggesting greater capacity for these characteristics.

Lastly, emotional tone implied overall emotional feeling of the text. Therefore, lower numbers would be indicative of a negative tone and higher scores indicating a more positive focus

(Pennebaker et al., 2015).

For the combined pages of the whole sample, the analytical thinking was 76.45. This suggested that the websites were written with at a higher level of formal thinking. A high number of 88.74 was produced for clout, which was indicative of high social status, greater confidence, and/or strong leadership. Authenticity scored a low number at 38.43, which is indicative of not demonstrating humility or being personable. Finally, 48.67 was the score for the overall emotional tone of the websites. Though close to the midpoint, being slightly under 50 suggested that the overall tone of the websites was slightly negative.

The other category scores that LIWC provided are considered percentages of the word count. For example, LIWC provided a score of 4.26 in the category positive emotion for the overall sample websites. This meant that about 4% of the words were positive emotion words.

This could include words, such as love, nice, or sweet (Tausczik & Pennebaker, 2010). The score for negative emotions was 3.02, meaning that 3% of the text was negative emotion words. MFT WEBSITES 45

Though only a slight increase, MFTs seem to be using more positive emotion words than negative emotions words on their website. Nevertheless, the percentage of positive emotion words is low and may be related to the more depressed overall emotional tone.

Other interesting categories worth mentioning were social, family, and focus (past, present, and future). About 14% of the words related to socialness and only 1.7% of the words related to family. MFTs seem to present a focus on relationships and sociality. For the focus categories, 1.2% of the text focused on the past, about 10% focused on the present, and 1% focused on the future. Thus, MFTs were more present focus.

Total Sample Home Page.

The word count for the combined sample Home page was 4,681. For the summary categories, the analytical thinking and clout scores were comparable to the overall sample pages combined, with 76.09 and 91.11 respectively. The analytical and clout scores were indicative of the Home pages showing higher level thinking and strong confidence and leadership.

Authenticity was 46.3, meaning lower levels of humility and being personable. However, the authenticity score was an increase from the overall sample pages combined, which may indicate an increased demonstration of authenticity on Home pages. Lastly, the emotional tone category was 66.22. The emotional tone score indicated that the overall emotional tone of the Home pages was positive. The emotional tone score was a significant increase from the overall sample pages combined, suggesting that the overall emotional tone changes depending on the page within the website.

With regard to positive and negative emotion words the scores were 5.23 and 3.10, respectively. The positive and negative scores signified that more positive than negative emotion words were being used on the Home pages. The scores for positive and negative words also MFT WEBSITES 46 seemed to fit with the increase in overall emotional tone. Social and family scores were comparable to the overall sample pages combined, with 14.7% and 1.45%, respectively.

Additionally, for the focus percentages the sample Home pages continued the notion of being present with less than 1% past focus, 10.5% present focus, and 1% future focus.

Total Sample About Me Page.

The word count for the combined sample About Me pages was 6,393 words or 15 pages.

There were more total words in the About Me page as compared to the Home page. The analytical thinking and clout scores remained high with 85.19 and 79.81, respectively. The analytical thinking was almost ten points higher than the overall sample pages combined. The analytical thinking score indicated even higher levels of formal thinking on the About Me page.

However, the clout score was almost ten points lower, with the overall sample pages combined having a score of 88.74. Though still a high number (79.81), the clout score signified a drop in textual confidence and leadership. Interestingly, the About Me page scores are quite comparable with the overall sample pages combined. The scores for authenticity and emotional tone were

36.88 and 48.09, respectively. The authenticity and emotional tone scores meant that the personable nature and humility demonstrated on the About Me page was low, and the overall emotional tone was negative. The scores for authenticity and emotional tone seemed unique, because the About Me page consistently was a place to describe the personal and professional self of the therapist.

However, despite the lower emotional tone there were still more positive emotion words than negative emotion words with 3.4% and 2.2%, respectively. The social category remained steady at 12.5% and the family category had a slight increase at 2.8%. Additionally, the past and MFT WEBSITES 47 future foci remained low at 1.4% and .5%, respectively. The present focus had decreased a few percentages, presenting at 7.7%.

Total Sample Approach Page.

The total word count for the total sample Approach pages was 20,546 words, making it the page with the greatest amount of textual information displayed. The Approach page word count could indicate that therapists place greater value on the information found on this page.

With regard to the summary categories, analytic thinking was similar to the overall sample pages combined with a score of 73.33. The analytical thinking score signified formal and logical thinking occurring on the Approach page. Clout was also high at 90.31, which was indicative of high confidence and social status. Authenticity and emotional tone were also comparable to the scores of the overall combined sample pages, with scores of 37.20 and 44.77, respectively.

Again, the authenticity and emotional tone scores were low and indicated a lack of humility, being personable, and an overall emotional tone that was negative.

For the other categories, positive emotion continued to be a higher percentage than negative emotion at 4.3% and 3.3%, respectively. The Approach page text was 14.3% social and

1.5% family. Moreover, the percentages for past focus, present focus, and future focus were

1.2%, 10.5%, and 1.2%, respectively. Again, the Approach page scores were comparable to the overall combined sample pages as well as the other two individual sample pages: Home and

About Me.

City Totals.

The following are tables that present the LIWC results for each city’s combined page total as well as the combined total for each individual page: Home, About Me, and Approach.

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Table 1 Atlanta Summary Emotional Categories Analytical Clout Authenticity Tone Total 80.98 89.41 32.02 66.47 Home 65.70 92.51 35.91 61.99 About Me 86.94 87.05 13.29 56.95 Approach 82.36 89.11 36.52 69.49

Table 2 Austin Summary Emotional Categories Analytical Clout Authenticity Tone Total 77.43 86.01 44.57 24.80 Home 66.89 93.28 62.38 78.26 About Me 89.86 68.81 39.76 22.12 Approach 74.70 87.80 41.62 15.31

Table 3 Boston Summary Emotional Categories Analytical Clout Authenticity Tone Total 70.51 92.69 37.43 42.72 Home 91.90 82.19 44.11 84.39 About Me 91.74 70.70 36.24 84.24 Approach 59.10 95.82 36.84 26.99

Table 4 Chicago Summary Emotional Categories Analytical Clout Authenticity Tone Total 76.18 83.73 44.63 43.35 Home 82.63 84.21 47.04 29.08 About Me 75.03 87.53 54.65 44.13 Approach 73.48 80.24 36.38 50.25

Table 5 Seattle Summary Emotional Categories Analytical Clout Authenticity Tone Total 74.55 90.40 34.67 70.74 Home 80.85 96.10 33.27 81.16 MFT WEBSITES 49

About Me 79.38 80.94 40.59 52.60 Approach 72.00 91.14 33.36 73.31

For each city, the analytical thinking and clout scores were relatively high, which was consistent with the totals for the combined websites. Again, the analytical thinking scores were indicative of higher-level thinking. For authenticity, the scores were relatively low within the thirty to forty range, indicating lower levels of humility and being personable. However, Austin’s

Home page and Chicago’s About Me page were not as low. Perhaps the most interesting and observable differences were in the emotional tone category. The emotional tone scores varied depending on the city. For example, Atlanta and Seattle had relatively high total scores for emotional tone, indicating a more positive emotional sound for their websites. Boston had a mix of high and low scores for their page totals, and Austin and Chicago had relatively low scores that were indicative of a negative emotional tone for their websites. Additionally, the Home page for each of the cities in the emotional tone category were high scores, with the exception of

Chicago (29.08). The emotional tone score for the Home page was interesting to note as the first page a potential client would see was the Home page for every website in this sample.

The results have implications for how the websites may sound to potential clients. The emotional tone, clout, authenticity, and analytic thinking categories provided insight into meaning portrayed by the website text. Overall, the websites were written at a high level of thought and demonstrated strong leadership and confidence. Furthermore, the websites as a whole had a negative tone and were not authentic or personable.

Qualitative Themes

To determine how MFTs describe their training and approach to therapy as well as their personal and professional selves, I conducted two rounds of coding in order to create themes from the data. Following Saldaña’s (2015) suggestion, the first round consisted of open coding. I MFT WEBSITES 50 created codes that fit the meaning of the idea being communicated by the data. I wanted to capture the meaning of the data as well as stay true to its natural form. In vivo coding (Miles et al., 2014) helped me to honor the language used by the therapists. Next, I conducted a second round of coding that entailed combining similar codes into a group. I then analyzed and interpreted the groups to create pattern codes or themes. Pattern codes are qualitative analytical inferences about the data that assist in describing phenomena (Miles et al., 2014). The themes provided meaning and described what was happening on the websites. These themes are presented from an analysis of 25 websites, and exemplars from the website data are provided to demonstrate the meaning of the theme.

Services, Specialties, and Populations.

The first things I was interested in were services, specialties and the population of interest. Almost all of the websites contained information regarding services, specialties, and population of interest making it seem like a common pattern. Frequently, I observed the services, specialties and the population intertwining with one another. For example, one therapist wrote:

“My practice is primarily focused on adults and adolescents.” (25.2)

This represented a specialty as well as a population focus of adults and adolescent children. This same therapist later went on to describe their services with this population as:

“Individual, Couple, & Family Therapy for Adults and Adolescents.” (25.2)

Other websites presented their services in a list fashion, such as:

“Experienced counseling services in the following practice areas: Individual & Group Counseling Couples Counseling Family Counseling Adolescent & Teen Counseling Alcohol & Drug Counseling Group Meetings” (23.2)

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Some expanded the definition of types of services to include example topical areas:

“I provide individual, couple, and family therapy in a supportive, safe, and non- judgmental environment.” (11.2)

“Individual Therapy - Become more self-aware of your thought patterns and behaviors Couples Therapy- Learn and practice good communication techniques and discuss difficult topics in a safe, and sometimes humorous environment Family Therapy- Work through issues as a family in the therapy room and learn how to create the same productive and fun environment back at home Group Therapy- Interact with other individuals on specific topics in a facilitated environment to discover how others cope and to gain emotional support Animal Assisted Therapy - Share a therapy session with a certified therapy dog who provides sense of comfort and acceptance for her clients.” (9.2)

As the exemplars suggest, there was often an interwoven description of services, specialties, and populations, making it difficult to separate the three. When specialties were easily identified they were typically observed in a column format:

“Adolescents Adoption Adult children of divorce Anxiety Career Communication Conflict Couples Depression Divorce Emerging adulthood Family of origin issues Grief/loss Infidelity Lifecycle transitions Premarital counseling School anxiety/refusal Self-esteem Sexual abuse Stress management Transition to parenthood Trauma Work/life balance” (19.2)

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Many of these appeared as a lengthy list of issues that seemed to communicate that they could work with nearly any issue. Other portrayals of specialties were observed in a paragraph format.

“My clinical expertise includes issues of adjustment, motivation, depression, acting out, ADD/ADHD, substance abuse/dependency and the tragedy of suicide and homicide. I am familiar with the challenges of single-parenting, blended families, parental limit setting, self-care and fostering personal responsibility and respect among family members.” (23.2)

Some therapists had more of a specific specialty, which was discussed and highlighted as a central aspect of their practice. This was particularly true for those offering sex therapy, but included other specialties as well.

“A sex therapist is a specialized professional trained in the treatment, study and management of all areas of dysfunction related to sexuality. Sex therapy does not include physical touch between you as the patient and me as the therapist. I will not ask you to undress at any time. I may request a full physical by an internist, general practitioner, or specialized gynecologist to rule out medical causes as a part of treatment.” (2.2)

“Hypnotherapy Do you have a habit that you just can't seem to get out of no matter how much you really really want to? Whether it's procrastination to addictions to intense emotional states, like fear...Heart Centered Hypnotherapy has been effective for supporting people who desire to break free from such issues in their lives...” (14.2)

“Quite often yoga, meditation, and breathing techniques have been successfully integrated into the treatment plan with positive outcomes.” (20.2)

One therapist mentioned multiple times that they were a lawyer turned therapist and heavily emphasized this throughout their website. It was clear after reading their website that they were targeting people in high stress jobs, particularly other lawyers. They even presented their J.D. credentials. They used words like burnout, stress and anxiety, particularly as they related to work/occupation. This excerpt captures the law profession well:

“LMFT-ASSOCIATE, J.D. As a lawyer turned therapist, I offer a unique perspective in my therapy practice. My main focus is to help people dealing with chronic stress, anxiety, depression, and MFT WEBSITES 53

relationship issues. I frequently work with professionals in demanding careers and can empathize with the challenges of a high-stress job.” (8.2)

It is also worth mentioning the insurance and fees associated with these services and specialties. I discovered that information regarding insurance and fees for the therapy services and specialties was minimally discussed. Of the 25 MFTs, only 12 mentioned the cost of each session. The fees ranged from $100 to $225. Fifteen of the 25 MFTs accepted insurance and only one did not report the type accepted. Additionally, 5 MFTs offered a sliding fee scale. However,

4 of the 5 MFTs that offered a sliding fee scale had limitations associated with the offer, such as limited spots available and having to apply for the position.

Training.

Almost all of the websites displayed information regarding therapist training and/or their credentials. The information was typically demonstrated with a list or statement of where the therapist attended college, what kind of degree they received, and a list of credentials from said degree or other training.

“Graduated from Georgia Southern University with a Bachelor's degree in Psychology in 2008 and graduated from Mercer University, School of Medicine with a Master's degree in 2011. I pursued my specialty license in south Florida with the Sex Therapy Training Institute and obtained this certification in 2014.” (2.2)

“Licensed Mental Health Counselor, LMHC, State of Washington Licensed Marriage & Family Therapist, LMFT, State of Washington American Association of Marriage & Family Therapist, AAMFT, Clinical Member, Approved Supervisor” (23.2)

Sometimes the therapist would provide their information in third person even when they had previously been writing in first person.

“A 2002 graduate of the University of Georgia with a degree in Child and Family Development, Amy Howard earned a master’s degree from Auburn University in 2005 in Marriage and Family Therapy.” (1.2)

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Approach: Holistic

It seemed important to examine the therapy approach, because most of the therapists discussed their approach on their websites. I looked for commonalities and created codes that captured the meaning of their description. I discovered that the website descriptions of the therapists’ approach were holistic, collaborative and client centered. Many of the therapists reported using multiple approaches, tailoring the theories and models to the client, and considering multiple contextual influences.

“I view your problems within the context of your unique set of relationships and life experience.” (24.2)

“I am trauma-informed and take a holistic approach to therapy that considers both the person and surrounding influences from family, work, community, and culture.” (8.2)

Additionally, therapists also described the qualities of their therapeutic style.

“By integrating talk therapy w/mind-body techniques, I provide comprehensive care. My therapeutic style is warm, open, down-to-earth and strengths-based.” (15.2)

“My approach to coaching and counseling is warm, interactive, and direct.” (22.2)

Approach: Collaborative.

One of the main marketing messages from the websites was that therapy would be a collaborative effort between the therapist and client. Therapy would not be a lecture or seminar, but rather an opportunity to work with the therapist in creating change.

“My approach is collaborative. Together, we explore the constraints that may be keeping one from their goals as well as identifying one’s strengths.” (17.2)

“We will work together to determine the best approach for you.” (15.2)

“I look forward to being your collaborator.” (13.2)

Therapist and clients were also seen as a team.

“Span of sessions will be decided on as a team…” (2.2)

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“Together, I will work with clients to co-create and experience.” (19.2)

Approach: Client-Centered.

The message of collaboration went a step further by describing the therapy process to be directed by the needs, desires, and goals of the client.

“…I believe my clients should always set the agenda and the pace of counseling.” (8.2)

“…I’ll work with you at your pace and comfort level and adapt our work to fit your needs and goals.” (18.2)

Therapists consistently reported on their websites that therapy would be personally tailored to the client.

“I provide quality and evidence-based care using a variety of modalities tailored to your individual needs.” (22.2)

“I avoid a ‘cookie-cutter’ approach, each client or couple is seen as unique. Treatment is custom-tailored to suit the case.” (20.2)

Description of MFT.

One of my research questions focused on how the therapists described MFT. It was important to understand how MFTs are marketing their profession. Again, I looked for common trends among the websites. However, from my analysis I observed that the description of MFT as a profession or specialty was not detailed nor discussed much on the websites. There were some that provided a brief line or definition.

“I view things from a systemic perspective, meaning that even as individuals, we are greatly impacted by our relationships.” (12.2)

“Marriage & Family Therapists are mental health professionals licensed to diagnose and treat mental/emotional disorders practicing with the theoretical orientation toward cultural/family origins.” (14.2)

Some made mention of MFT words or phrases, such as systems perspective or systems therapist, but did not define or discuss what this meant for a potential client. MFT WEBSITES 56

“I am a systems therapist who specializes in dealing with children, parents, couples, and family dynamics.” (9.2)

“I’ll also be relying on my training in couples therapy, psychoanalytic psychotherapy, Gestalt therapy, and family systems therapy.” (13.2)

There were a few therapists that provided a thoughtful description of MFT.

“Absolutely. Marriage and family therapy, also commonly known as systemic therapy, simply refers to the idea that as therapists, we view people through the lens of relationships.” (19.2)

“I am a Marriage & Family Systems oriented therapist, which means that I look through the lens of identifying patterns rather than solely the presenting issue, problem or person. Systems Therapists are trained to understand the context of individual, that is - Family, Community, Society, Culture, etc. No one lives in a vacuum.” (14.2)

One therapist provided almost an entire page of psychotherapy history that included MFT history.

“By the 1960's, many therapists were finding that clients were often better able to sustain changes in their behavior---and that both the client and the client's relationships with the family were influenced positively---when family members were included. They also found that, in order to work effectively with couples and families, they needed to learn a different "mindset" and to develop additional clinical skills. As universities and institutes developed programs to train therapists to do this work, the American Association of Marriage and Family Therapy was established to promote consistently high standards nationwide for the training, practice and licensing of MFT's, and to serve as a resource about Family Therapy. A substantial amount of additional coursework and supervised clinical experience with couples and families is required---beyond what is required for Professional Counselors-- -in order to be licensed as a Marriage and Family Therapist.” (3.2)

The therapists’ description of MFT seemed to focus on systems thinking or having a relationship perspective. However, the sample as a whole did not seem to define themselves as a therapy profession nor distinguish MFT from other counseling-related fields.

Therapist Description: Professional.

The description of the therapist was another area I examined. The therapist description seemed important as potential clients will likely seek to learn about the therapist. I examined the MFT WEBSITES 57 websites for qualities and characteristics that the therapists seemed to use to portray themselves.

I again searched for commonalities and descriptors that captured the sense of the therapist. From my analysis, I discovered that MFTs described themselves as a professional as well as a non- professional. First, the professional side of the therapists was described based on their role as a therapist. Though the websites had a variety of words to describe the role of the therapist, the overall theme resided on the therapist being a helper.

“I am just there to help them navigate their path to reach a level of balance and acceptance with the strengths that already exist.” (21.2)

“Many people also find that counselors can be a tremendous asset to managing personal growth, interpersonal relationships, family concerns, marriage issues, and the hassles of daily life. Therapists can provide a fresh perspective on a difficult problem or point you in the direction of a solution.” (16.2)

Even in the circumstances of negative motivation (described below), the therapists sometimes concluded with the consistent message that they could help.

“Whether you are looking to strengthen you relationship or seeking therapy due to concerns about the relationship, I am here to help.” (4.2)

“If you are tired and ready for a change to happen in your life, then I am here to help.” (6.2)

The second professional description was based on the qualities that make them a good therapist. Many therapists described themselves as warm, compassionate, safe, and non- judgmental.

“As a warm and compassionate person, I provide a judgment-free space for you to explore…” (18.2)

“I use warmth, compassion, and at times humor…” (17.2)

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Therapist Description: Personal.

A few of the therapists provided some personal information. The information included items such as their journey into the therapy career, personal experiences with therapy, family information, and fun facts.

“Peggy’s most valuable experience has been in being “all in” with the joy and vulnerabilities of family life as a wife to Neil, mother of 2 boys and 2 daughters-in-law. Peggy’s hobbies include painting, Pilates, and traveling the world with her husband.” (5.2)

“A therapist in therapy? Yes, I have benefited from therapy at different times in my life. Just like everyone else, I have experienced relationship issues, personal challenges, and loss. I chose to process my thoughts and feelings in a safe, empathetic, and warm environment that was, most of all, free of judgment. In my experience, I felt more connected and understood by therapists who had themselves been in therapy. I felt like they “got it” because they had been there too.” (18.2)

Pressure to Convey.

Another theme from the data described the therapists’ motivation for writing. It was frequently observed that therapists wrote multiple points and ideas in any given paragraph and even a sentence. There seemed to be this pressure to convey all the necessary information in order to appropriately market or obtain the attention and business from the potential client reading the website. My initial approach to coding was to code by idea, which could include a couple of sentences to a whole paragraph. However, because of the pressure to convey, I switched to more of a line-by-line coding process in order to capture all of the ideas. This paragraph is packed with adjectives and ideas:

“As a practical, interactive and relationship oriented cognitive behavioral and solution- focused therapist, my treatment and counseling approach is to provide support with insight and feedback to help clients address anxiety, depression, stress, relapse, grief, relationship issues, life transitions, current challenges and long-standing issues. With sensitivity and compassion, I help individuals, families and couples bring resolution to a wide range of life challenges and issues. I provide couples therapy, family therapy, depression and anxiety therapy in Palos Heights, IL and in the Chicago area.” (16.2)

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This therapist started the paragraph with a sentence about another expertise with substance abuse and then does not return to it in the rest of the paragraph:

“My second expertise is substance abuse which is plaguing the society and families. My therapeutic approach is to provide support and practical feedback to help clients effectively address personal life challenges. I integrate complimentary methodologies and techniques to offer a highly personalized approach tailored to each client. With compassion and understanding, I work with each individual to help build on their strengths and attain the personal growth they are committed to accomplishing.” (10.2)

On another website, this excerpt was written twice, verbatim:

“I view your problems within the context of your unique set of relationships and life experiences. You may be stuck in repetitive patterns that do not utilize your personal strengths to your fullest potential. Therefore, my approach involves identifying your strengths and proposing a treatment plan that utilizes them. In the case of couples and family therapy, each person’s individual strengths are identified, as well as the strengths of the couple and/or family as a whole systemic unit. My approach, in general, is to provide a safe, comfortable and supportive environment for every person to learn and grow within themselves, their relationships, and their experiences.” (24.2)

Negative Motivation.

From my coding of the website data, a theme of negative motivation was revealed. Many of the therapists seemed to describe the client’s desire or need to come to therapy through negative feelings, behaviors, and experiences that had become too overwhelming or unmanageable.

“You probably feel worn out and hopeless when you consider all the ways you have tried to fix your relationship.” (6.2)

“Perhaps you might not feel appreciated, heard or validated. Or maybe you grew up that way and now find yourself repeating the same dysfunctional thoughts about yourself. Sometimes we find ourselves ruminating to exhaustion.” (18.2)

Some even asked questions to the reader regarding these negative feelings as a means to suggest the need for therapy.

“Do you feel lost, confused, alone, or depressed? Have you looked in the mirror lately and not recognized the person that you have become?” (21.2) MFT WEBSITES 60

“DO YOU FEEL STUCK IN YOUR LIFE OR CAREER? Do you have a hard time managing stress? Or are you buried under fatigue, anxiety or depression and unable to pull yourself out of it? Do you know there is a better way of life but, despite your best efforts, you can’t seem to get there?” (8.2)

Whether as a strategic scare tactic, an attempt to validate, or a blunt opinion, others seemed to provide a warning if action was not taken.

“You don't want to become another divorce statistic, you want to grow together, not apart.” (15.2)

“Unfortunately, many couples decide to seek therapy once their relationship has reached a breaking point. Therapy seems to be the last attempt to save the relationship. Many have lost their hope to recover their relationship. At this point, one regular 50 minute session might not allow enough time to process the situation…” (7.2)

Message of Hope.

Though many of the therapist websites expressed a negative motivation to choose therapy, many followed up or provided a message of hope. They suggested that things could improve and the client could achieve a better life. The positive messages that therapists communicated centered around themes of hope and transformation.

“I am here to offer you hope.” (6.2)

“You don’t have to live in that hurtful place. There is always space for repair, healing, and growth.” (7.2)

It was presented to clients and potential clients that when they could not imagine hope, the therapist would carry it for them and help them obtain it.

“I am here to help hold the hope for you when you are not able to do it for yourself.” (21.2)

“I am committed to providing a safe and accepting environment where individuals and families can find help and hope while looking to make a change in their lives.” (9.2)

One therapist even propagated that it was the client’s right to hope.

“You deserve help and healing, as happiness is your birthright.” (20.2) MFT WEBSITES 61

Furthermore, challenging times could yield positive results.

“I find these times of change and transition to hold tremendous opportunities for positive growth, healing, and renewal.” (22.2)

Potential to Transform.

The idea of hope seemed to lead to a message of transformation, in which the client could renew, rebuild, rediscover, revitalize, and ultimately become a new person.

“Whether motivated by a specific event or simply the desire for change, entering therapy represents your first step forward in the transformation process.” (19.2)

“Life just gets awful sometimes and it is about rediscovering the good within ones self, to see that you are powerful and can create a better meaning.” (21.2)

The therapists used a lot of action verbs that depicted the process for which transformation could be achieved.

“We will unearth long-standing behavior patterns or negative perceptions that may be holding you back from experiencing a more fulfilling and meaningful life.” (10.2)

“IT’S ALL ABOUT BREAKING FREE!” (14.2)

“I help individuals maximize their personal strength and potential.” (21.2)

“Discover the power of their own healing potential.” (20.2)

Summary

From my analysis, I was able to create themes that captured the meaning of the data and described the phenomena occurring on the MFT websites. I discovered the themes by coding the data, grouping similar codes together, and ultimately creating a theme that interpreted the meaning of the data. Additionally, by using the LIWC software I was able to obtain results that further described the textual data as well as assisted the coding process. The results from the coding comprised the services and specialties that the therapists offered as well as to what population they were offered. Additionally, themes about the messages being communicated to MFT WEBSITES 62 potential clients were identified. Messages of hope and transformation were strongly promulgated by the therapists, encouraging the potential client to seek help in order to improve.

Therapists also seemed to motivate clients by highlighting the negative feelings, thoughts, or experiences the potential client may be experiencing. Furthermore, therapists seemed to feel pressured to convey a large amount of information and demonstrated this pressure by overloading their paragraphs and sentences with multiple ideas. Yet, despite all the shared information, MFTs did not provide a strong description of MFT services nor distinguish the

MFT field from other counseling disciplines.

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CHAPTER 5: DISCUSSION

Marriage and Family Therapists (MFTs) effectively treat clients with a variety of issues

(Lundblad & Hansson, 2006; Sprenkle, 2003). However, it is not understood how MFTs market their services to potential clients. The present study examined therapist websites in order to gain greater understanding regarding therapist passive marketing strategies employed by MFTs. Little to no research has occurred regarding MFT marketing strategies, making this a discovery-based study. Globally, billions of people are using the internet (Internet World Stats, 2019). Many are seeking help through online services (PewResearch, 2009) and websites can have a strong impact on their choices (Bačik & Fedorko, 2016). MFTs are using professional websites to market themselves and their services to potential clients. However, little is known about MFT marketing practices via their websites.

As a qualitative content analysis framework was used to examine the MFT websites, the researcher will use the first person when referring to research conducted. By using the Linguistic

Inquire Word Count (LIWC; Pennebaker et al., 2005), a linguistic analysis software program, I discovered counts and categorical figures that assisted with understanding the tone and content of the website text. I also used Dedoose (Dedoose, 2014), which assisted with the organization, coding, and creation of themes from the website data, helping to describe the data as a whole.

Two rounds of coding occurred: open coding and pattern coding. Open coding provided initial ideas as to the meaning of the data. Pattern coding allowed for the combination of similar codes and the creation of inferences regarding the meaning of the data. The coding processes ultimately led to the creation of themes that described what and how therapists were marketing on the websites. The themes, with accompanying excerpts, were presented in the results chapter, and are further discussed here. Limitations and suggestions for future research will also be outline. MFT WEBSITES 64

Photos

One of the prominent features on the MFT websites were photos and images. Almost all of the websites contained photos. However, it is unknown as to the effect of using photos on

MFT websites. More research is needed to capture the meaning and effectiveness of photos on

MFT websites. Some research indicates that photos are a good way to demonstrate what something is like (Tang, 2011). Furthermore, aesthetically appealing websites have been shown to increase enrollment at universities (Jones, 2006). Thus, photos on therapist websites could have a similar influence by attracting and increasing client participation in therapy. It is also worth mentioning that there were two therapists that provided an embedded YouTube video to describe themselves and their therapy services. One in particular provided multiple videos that discussed the topic of the webpage. Use of the YouTube videos was unique and added variation, which suggests a new potential to online marketing. With the increasing capabilities of technology and social media it leaves one wondering about the effectiveness of new online features. Being able to hear the therapist’s voice and see their body language could have an even stronger influence when determining the therapist fit for a potential client, and more research is needed in this area.

LIWC

I used the LIWC software program to analyze the textual data from the MFT websites.

Results suggested higher level of thought and formal writing as well as confidence and leadership, but low levels for the qualities of being personable and humble. The emotional tone suggested an overall negative tone for the MFT websites. Taken together, these results suggest that MFTs present themselves and their services negatively to potential clients. Additionally, with low levels of authenticity there is likely to be a lack of client engagement and loyalty to the MFT WEBSITES 65 brand (Rossiter & Bellman, 2012). Positive emotional tones create a sense of trust and genuineness, which may increase potential client engagement (Rossiter & Bellman, 2012). MFTs should consider the impact that perceptions of low authenticity and negative emotional tone have on potential clients. Increasing the use of positive emotion words may make a difference. There was some variation seen across cities. Specifically, Seattle had higher scores with emotional tone, suggesting a potential phenomenon occurring in Seattle. However, as a whole, the sample had low scores for emotional tone. Research has shown that clients have expectations (Tambling,

2012), and that these expectations influence therapy outcomes (Dew & Bickman, 2005;

Tambling, 2012). Many clients expect the therapist to be kind, friendly, and welcoming

(Tambling, Wong, & Anderson, 2014) as well as warm and caring (Tambling & Johnson, 2010).

Therefore, the overall negative tone may hinder the effectiveness of MFT websites and may dissuade potential clients from engaging in services that do not seem to match their expectations.

Services, Specialties, and Populations

Therapists often portrayed services, specialties, and populations served in ways that were interconnected and difficult to distinguish, even for the researcher who is a trained MFT.

Additionally, when therapists described their services and specialties they frequently appeared as a long column of things they could treat or do. This seemed to indicate that the therapist was able to treat nearly any issue, or no issue at all. It is important for MFTs to consider how the portrayal of many services and specialties influences the potential client to engage with them in therapy, and how accessible the language used by therapists is to the lay reader. Research indicates that written language should be easily understood by the reader (Askehave & Zethsen, 2002; Pitta,

1998). Along with the long specialty lists, MFTs displayed lengthy descriptions on specific specialties, like sex therapy or hypnotherapy. There was a sense that MFTs were competing MFT WEBSITES 66 amongst each other, or their graduate cohort, in order to be the more attractive option for potential clients. Thus, instead of creating a unified brand as a field, MFTs seemed to construct a picture of competition and separation.

Additionally, information regarding the insurance and fees, associated with the services and specialties offered, was minimally discussed. Many MFTs did not provide information regarding the cost of a therapy session. MFTs that did display the cost of therapy reported amounts that seemed high. Moreover, only five MFTs offered a sliding fee scale to help offset the expensiveness of therapy. However, four of the five had limitations associated with this offer.

Research indicates that the cost of therapy (Fugate, Landis, Riordan, Naureckas, & Engel, 2005) and insurance availability (Venner et al., 2012) can be significant barriers to client initiation of and attendance in therapy. Furthermore, there are ethical issues to consider with regard to MFTs serving the community. The AAMFT code of ethics reports that MFTs should offer some of their time to providing therapy services at little to no cost (AAMFT, 2019b). MFTs should reevaluate how their services are improving client initiation and participation in therapy as well as adhering to AAMFT’s ethical guidelines.

Pressure to Convey

Another theme I observed from reading and analyzing the website data was a pressure to put multiple ideas into just one sentence. My initial approach to coding the data was to code by idea, meaning, I would code every few sentences or even provide one code for a single paragraph. However, many of the therapists conveyed multiple points in a single sentence, making it difficult to code per idea and still capture the true meaning of the data. Providing a lot of information into one sentence or paragraph may appear disjointed or confusing to potential clients. There were two websites that demonstrated more concise and brief explanations, even MFT WEBSITES 67 having only one or two pages within their website. Nevertheless, as a whole, the sample demonstrated pressured and lengthy writing. Furthermore, combining multiple ideas into a single sentence may increase reading level difficulty and may make language use less accessible to nonnative speakers. One research study reported that Hispanics surpassed Caucasians for being more likely to search mental health information online (Fox & Jones, 2009). Therapists should thoughtfully consider both the reading level and accessibility of their websites.

Approach

The description of MFTs approach focused on three themes: holistic, collaborative, and client-centered. Though this was not a specific definition or description of MFT, the holistic approach is consistent with several values endorsed by many therapists (Bozarth, Zimring, &

Tausch, 2002; Cattich & Knudson-Martin, 2009). What is less well known is how well these common terms within the field are understood by potential clients, and how well these ideas might fit with expectations. Research suggests that clients expect a therapist who is expert

(Tambling et al., 2014), and ideas such as collaborative and client centered may not fit with expectations, potentially deterring prospective clients. More research is needed to determine how messages and language used by therapists is perceived by prospective clients.

Description of MFT

One of the more evident observations from the analysis was the lack of description of

MFT. Literature strongly suggests that branding one’s company and product are crucial to attracting customers and influencing them to become consumers (Backhaus & Tikhoo, 2004;

Change et al., 2019). Unfortunately, the current MFT branding process appeared weak. In the unusual case in which a therapist did provide a description of MFT services, it was brief. There were some that provided descriptions of MFT by mentioning concepts and terms regarding MFT WEBSITES 68 systems thinking, relationship perspective, and theoretical framework. However, the terms were not defined. MFT terminology is likely unfamiliar to the lay reader and needs to be explained to potential clients. Research has shown that good marketing can decrease stigma (Brown, 2017;

Lannin et al., 2017) and increase client participation in therapy (Chaturvedi, 2016), and it is unclear the extent to which branding influences positive outcomes. Furthermore, more positive and clear branding will likely create consumer confidence and enhance credibility (Balmer,

2012), all outcomes that may lead to increases in client engagement with MFT services. It would benefit MFT as a field to consider the words and phrases needed to define themselves, attract potential clients, and help potential clients make appropriate decisions during their therapy initiation process.

Therapist Description

Therapists seemed to describe themselves personally and professionally. The personal description was less common and typically contained information about their family, their interests/hobbies, as well as their own experience as a client in therapy. Additionally, there was variation among therapists describing personal information, with some sharing more than others.

Communicating personal information as an identified professional can have mixed results

(Henretty & Levitt, 2010). Self-disclosure can benefit the therapeutic alliance (Hill & Knox,

2001), but therapists have been cautioned to use it appropriately and even sparingly (Knox &

Hill, 2003) to avoid alienating some clients. Thus, the sharing of personal information online is an interesting idea, but should be considered with caution and be further investigated.

The therapists also spent time on the websites describing themselves as a professional.

Two common trends emerged from my analysis of this area: therapist as a helper and positive qualities of a therapist. Repeatedly, therapists wrote about their role in the therapy process as MFT WEBSITES 69 helping the client to develop skills, assisting them to discover their strengths, and supporting their goal to rekindle their relationship. The second trend was the qualities communicated about the therapist. Many used words, such as warm, compassionate, and understanding. They similarly reported that they would provide a safe, non-judgmental space. Interestingly, the listed qualities were similar to what clients expect from their therapist (Tambling et al., 2014;

Tambling & Johnson, 2010), which may positively influence potential clients and increase therapy seeking behavior.

Negative Motivation

Another significant theme to emerge from the data was that of negative motivation.

Therapists seemed to consistently communicate the message to potential clients that they should come to therapy because of something bad, wrong, or negative was affecting them. Thus, therapists seemed to highlight potential symptoms or situations the client could be experiencing, with the intent to increase their desire to seek help. The results I obtained from the LIWC program appeared to support this theme, with scores indicating an overall negative tone in the textual data. This strategy is commonly seen in marketing, where companies provide a negative motive (Barone, Norman, & Miyazaki, 2007), negative symbolism (Banister & Hogg, 2004), or even become manipulative (Landefeld & Steinman, 2009). Emotions play a fundamental role in marketing and branding (Hartmann et al., 2005; Thompson et al., 2006). Therapists were making use of emotions, such as hopelessness, sadness, despair, and depression, to influence the client’s decision-making process. It behooves therapists to consider the impact of their marketing via negative motivation, and how this might potentially impact motivation to engage in the tasks of therapy (Tambling, 2019). MFT WEBSITES 70

Furthermore, therapists should consider using more normalizing language in order to alleviate initial concerns and to better relate with potential clients. The therapeutic alliance is the most predictive factor of therapy success (Horvath, Del Re, Flückiger, & Symonds, 2011). The therapists’ websites could be the first therapy-client interaction. Therefore, MFTs are strongly urged to consider how they are establishing the therapy alliance through their passive marketing practices prior to clients participating in therapy.

Hope and Transformation

Despite the negative motivation identified on the websites, the therapists also appeared to use positive emotions to inspire clients to come to therapy and make healthy changes. By using the LIWC, I discovered that the overall emotional tone of the websites was negative. However, in a numerical count, the MFT websites had a higher percentage of positive emotion words

(4.3%) in comparison to negative emotion words (3%). This was not a huge difference, but was still indicative of therapists using positive emotion vernacular.

Common words therapists used, included unearth, discover, rebuild, revitalize, and transform, which led to the theme of transformation. Therapists communicated to potential clients that there was hope to experience a new creation of self. Therapy can be a great place for exploration and for this transformation process to occur (Kopp, 2013). Highlighting this notion on the websites seemed to be a positive way to help clients initiate therapy. However, it is important to consider whether potential clients really want to become a new person. The language of self-renewal may not be a fitting goal for potential clients, and therefore repel potential clients from participating in therapy.

MFT WEBSITES 71

Clinical Implications

Taken together, the results of this study have important implications for the field of MFT.

This is one of the first studies that examined MFT websites, an example of passive marketing techniques used by MFTs to attract potential clients. It was not well understood what MFTs were doing to market themselves nor how they were doing it. This study closes the gap in the literature. The websites revealed that therapists highlight their training and expertise as well as the areas in which they specialize. The themes produced from the analysis provided insight into the types of messages being communicated such as negative motivation, therapist role and quality, and their client-centered, collaborative, and holistic approach. Furthermore, this study revealed current trends in online marketing of therapy. All of these findings provided more knowledge and understanding of the marketing practices of MFTs.

The present study also revealed that MFTs do not explain what MFT means. Very few therapists provided any discussion about MFT. The therapists that did provide some description of MFT usually incorporated other terms, such as systems thinking or theoretical framework, but the terms were not defined. As a field, MFTs appeared to assume that the potential clients already understood what MFT means. Additionally, the therapists did not distinguish themselves from other professional therapy services or fields. MFTs need to be aware of how they are representing themselves and their discipline. Clients have expectations about the therapist and about therapy (Tambling, 2012). In order to effectively help potential clients, MFTs need to understand and meet the clients’ expectations. Further research and education are needed in order to better prepare MFTs to appropriately market themselves, their services, and the MFT field.

It is now understood that MFTs have a negative tone on their websites. The scores for emotional tone were consistently low for the MFT websites. We do not understand what kind of MFT WEBSITES 72 an influence the negative tone may have on potential clients. Additionally, MFTs commonly motivated clients through negative emotions. The therapists repeatedly discussed the potential negative emotions and symptoms clients may be experiencing, which were suggested as the reason potential clients should attend therapy. It would benefit therapists to examine their use of negative emotions in order to determine its efficacy or disadvantage. Furthermore, MFTs also highlighted hope and the possibility of transformation by coming to therapy. The message of hope and transformation provided the potential clients a glimpse of what they could achieve.

However, the positive message seemed to always come after the negative motivation. The relationship that therapists develop with clients is the most significant predictor of client success in therapy (Horvath et al., 2011). Therapists appear to be sending a mixed message to potential clients, and therapists would do well to consider the ambiguity of the two messages combined.

The negative and positive messages could be negatively influencing the therapist-client relationship.

Limitations

This study was not without its limitations. Likely, the biggest limitation was that the design of this study was not able to produce an answer as to why MFTs have created their websites in the manner they have displayed them. This study only examined the websites and did not engage with the creators of said websites. Therefore, there were unanswered questions that will require more studies and different methodological approaches. Future studies would do well to focus on interviewing MFTs who have created a website in order to gain a greater understanding to their process in said creation and how they learned or were inspired to market themselves and their services. It is hoped that this study provided results that will support future interview questions and help researchers hone in on areas that merit further exploration. MFT WEBSITES 73

Another limitation to the study was the lack of comparison between urban and rural settings. As was discussed in the literature review, rural therapists confront challenges that are different to urban areas (Cohn & Hastings, 2013). Because this study was one of the first to examine and navigate the realm of MFT websites the focus was more on establishing a foundation on which to build. A comparative study between different demographics would merit from greater information provided by this study. The sample focused on major cities across the

U.S. that represented different regions, with the hope to improve generalizability. However, the major cities selected were not all encompassing, which limits generalizability of the results.

Additionally, the selected websites only included solo practices and not group practices. Group or agency websites are a different therapist/treatment setting and would merit their own analysis and study.

Researcher bias was another potential limitation to this study. With the design heavily focused on qualitative methodology, the results are likely to be strongly influenced by the researcher’s personal perspective (Anderson, 2010). Though I made significant effort to decrease personal biases from influencing the data by way of jottings, memos, self-reflection, and counsel with colleagues, my worldview was undoubtedly a part of the analysis process. Miles and colleagues (2014) remarked that the power of qualitative research is found in the command over the analysis process. I believe my preparation and appropriately acquired knowledge greatly improved the effectiveness and meaningfulness of the study.

From my analysis using the LIWC program, valuable results were provided that increased understanding of the website data. However, the LIWC program does have its limitations. Like many software programs (Alexa & Zuell, 2000), the LIWC may not capture and demonstrate all the meaning from the data. Additionally, the LIWC program is based on pre- MFT WEBSITES 74 established categories. Thus, words could be overlooked, and thereby, change the meaning of the scores and percentages produced. Last, though many of the categories displayed types of words selected from the data, some categories did not. This included the four summative dimensions: analytical thinking, clout, authenticity, and emotional tone. The inability to see what words were coded limits understanding and validity of the results.

Future Research

With a solid foundation from which to build, researchers can more effectively continue exploration of MFT marketing strategies. In particular, future research should focus on interviewing therapists in order to understand why they created the websites as they did. These interviews would gather information regarding any knowledge or training the MFTs received in creating the websites or provide the sources of influence for online marketing.

Additionally, data could be obtained as to whether the websites were effective in reaching out to clients and building a practice. Researchers could examine how many “hits” a website receives, or how many unique visitors sites enjoy. They could determine differences in therapy success by interviewing therapists that do and do not have a professional website. The interview could provide substantial information that would lead to improvements in MFT marketing practices.

Another important area to study is whether or not the marketing tactics employed by

MFTs through websites are attractive to potential client populations, and whether current practices effectively engage clients. Researchers should interview clients and ask them about their experience with seeking therapy and whether they looked at therapist websites. Researchers could have current or potential clients rate the effectiveness of websites, report their likes and dislikes, and provide ideas for improvement. MFT WEBSITES 75

Conclusion

The present study provided knowledge regarding passive marketing practices via MFT websites. The findings significantly contribute to the field by providing a foundational understanding of what and how MFTs market online as well as the prominent messages communicated to potential clients. Furthermore, this study highlighted the importance for MFTs to establish a personal and professional brand via their online marketing. Therefore, this study opens the conversation for more research and understanding regarding effective therapy marketing practices.

MFT WEBSITES 76

References

AAMFT. (2019a). About Marriage and Family Therapists. American Association of Marriage

and Family Therapy. Retrieved from

https://www.aamft.org/About_AAMFT/About_Marriage_and_Family_Therapists.aspx

AAMFT. (2019b). Code of Ethics. American Association of Marriage and Family Therapy.

Retrieved from https://www.aamft.org/Legal_Ethics/Code_of_Ethics.aspx

ACA. (2019). About Us. American Counseling Association. Retrieved from

https://www.counseling.org/about-us/about-aca

Addis, M., E., & Mahalik, J. R. (2003). Men, Masculinity, and the Contexts of Help Seeking.

American Psychologis, 58(1), 5-14. doi:10.1037/0003-066X58.1.5

Alexa, M., & Zuell, C. (2000). Text analysis software: Commonalities, differences and

limitations: The results of a review. Quality and Quantity, 34(3), 299-321.

Anderson, C. (2010). Presenting and evaluating qualitative research. American journal of

pharmaceutical education, 74(8), 141-146.

APA. (2019). APA History. American Psychological Association. Retrieved from

https://www.apa.org/about/apa/archives/apa-history

Askehave, I., & Zethsen, K. K. (2002). Translating for laymen. Perspectives: Studies in

Translatology, 10(1), 15-29.

Azuine, R. E., Singh, G. K., Ghandour, R. M., & Kogan, M. D. (2015). Geographic,

racial/ethnic, and Sociodemographic disparities in parent-reported receipt of family-

centered care among US children. International journal of family medicine, 2015, 1-17.

doi:10.1155/2015/168521 MFT WEBSITES 77

Bačík, R., & Fedorko, I. (2016). The impact of usability of a website on recommendations by its

visitors. Exclusive e-Journal: Economy & Society & Environment, 1-7.

Backhaus, K., & Tikoo, S. (2004). Conceptualizing and researching employer branding. Career

development international, 9(5), 501-517.

Balmer, J. M. (2012). Corporate brand management imperatives: custodianship, credibility, and

calibration. California Management Review, 54(3), 6-33.

Balmer, J. M., & Gray, E. R. (2003). Corporate brands: what are they? What of them?. European

journal of marketing, 37(7/8), 972-997.

Banister, E. N., & Hogg, M. K. (2004). Negative symbolic consumption and consumers’ drive

for self-esteem: The case of the fashion industry. European Journal of Marketing, 38(7),

850-868.

Bantum, E. O. C., & Owen, J. E. (2009). Evaluating the validity of computerized content

analysis programs for identification of emotional expression in cancer

narratives. Psychological assessment, 21(1), 79.

Barone, M. J., Norman, A. T., & Miyazaki, A. D. (2007). Consumer response to retailer use of

cause-related marketing: Is more fit better?. Journal of Retailing, 83(4), 437-445.

Baruah, T. D. (2012). Effectiveness of social media as a tool of communication and its potential

for technology enabled connections: A micro level study. International Journal of

Scientific and Research Publications, 2(5), 1-10. doi:10.1.1.376.5533

Beck, R., & Fernandez, E. (1998). Cognitive-behavioral therapy in the treatment of anger: A

meta-analysis. Cognitive therapy and research, 22(1), 63-74.

doi:10.1023/A:1018763902991 MFT WEBSITES 78

Berger, R. (2015). Now I see it, now I don’t: Researcher’s position and reflexivity in qualitative

research. Qualitative research, 15(2), 219-234.

Beruchashvili, M., Moisio, R., & Gentry, J. W. (2015). Cultivating hope. Journal of Consumer

Culture, 15(3), 307-328.

Blow, A. J., & Sprenkle, D. H. (2001). Common factors across theories of marriage and family

therapy: A modified Delphi study. Journal of marital and family therapy, 27(3), 385-401.

Bozarth, J. D., Zimring, F. M., & Tausch, R. (2002). Client-centered therapy: The evolution of

revolution. Humanistic Psychotherapies: Handbook of Research and Practice. 147-188.

doi:10.1037/10439005

Brown, S. A. (2017). The Effects of Direct-To-Consumer-Advertising on Mental Illness Beliefs

and Stigma. Community mental health journal, 53(5), 534-541. doi:10.1007/s10597-017-

0121-z

Bureau of Labor Statistics. (2019). U.S. Department of Labor. Occupational Outlook Handbook:

Marriage and Family Therapists. Retrieved from https://www.bls.gov/ooh/community-

and-social-service/marriage-and-family-therapists.htm?view_full#tab-6

Carr, A. (2009a). The effectiveness of family therapy and systemic interventions for adult‐

focused problems. Journal of family therapy, 31(1), 46-74.

Carr, A. (2009b). The effectiveness of family therapy and systemic interventions for child‐

focused problems. Journal of family therapy, 31(1), 3-45.

Cattich, J., & Knudson‐Martin, C. (2009). Spirituality and relationship: A holistic analysis of

how couples cope with diabetes. Journal of Marital and Family Therapy, 35(1), 111-124. MFT WEBSITES 79

Chang, K. C., Hsu, C. L., Chen, M. C., & Kuo, N. T. (2019). How a branded website creates

customer purchase intentions. Total Quality Management & Business Excellence, 30(3-

4), 422-446.

Charmaz, K. (2008). Grounded Theory as an Emergent Method. In S. N. Hesse-Biber & P.

Leavy (Eds), Handbook of Emergent Methods (pp. 155-172). New York: The Guilford

Press.

Chaturvedi, S. (2016). Accessing psychological therapies: Homeless young people's views on

barriers and facilitators. Counselling and Psychotherapy Research, 16(1), 54-63.

Churchill, R., Hunot, V., Corney, R., Knapp, M., McGuire, H., Tylee, A., & Wessely, S. (2002).

A Systematic Review of Controlled Trials of the Effectiveness and Cost-Effectiveness of

Brief Psychological Treatments for Depression. Health Technology Assessment, 5(35), 1-

6. doi:10.3310/hta5350

Cohn, T., & Hastings, S. (2013). Building a practice in rural settings: Special

considerations. Journal of Mental Health Counseling, 35(3), 228-244.

doi:10.17744/mehc.35.3.12171572424wxhll

Colburn, A. (2013). Endless possibilities: Diversifying service options in private

practice. Journal of Mental Health Counseling, 35(3), 198-210.

doi:10.17744/mehc.35.3.8870230745378517

Cole, F. L. (1988). Content analysis: process and application. Clinical Nurse Specialist, 2(1), 53-

57.

Cooper-Haber, K., & Haber, R. (2015). Training Family Therapists for Working in the

Schools. Contemporary Family Therapy, 37(4), 341-350. MFT WEBSITES 80

Crane, D. R., & Payne, S. H. (2011). Individual versus family psychotherapy in managed care:

Comparing the costs of treatment by the mental health professions. Journal of Marital

and Family Therapy, 37(3), 273-289.

Creswell, J. W. (2014). Research Design: Qualitative, Quantitative, and Mixed Methods

Approaches. Sage.

D’Abate, D. A. (2016). Use of solution-focused and family narrative approaches in working with

high conflict families: Strategies and techniques that can be utilized in parenting

coordination and co-parenting coaching. Journal of Child Custody: Research, Issues, and

Practices, 12(4), 269-288. doi:10.1080/15379418.2016.1247308

Data USA. (2016). Data USA: Marriage and family therapy. Retrieved from

https://datausa.io/profile/cip/511505/

De Arellano, M. A., Waldrop, A. E., Deblinger, E., Cohen, J. A., Danielson, C. K., &

Mannarino, A. R. (2005). Community outreach program for child victims of traumatic

events: A community-based project for underserved populations. Behavior

Modification, 29(1), 130-155.

Dedoose Software. (2014). Dedoose: Great research made easy.

Dembo, J. S., & Clemens, N. A. (2013). The ethics of providing hope in psychotherapy. Journal

of Psychiatric Practice, 19(4), 316-322.

Dew, S. E., & Bickman, L. (2005). Client expectancies about therapy. Mental Health Services

Research, 7(1), 21-33.

Doss, B. D., Atkins, D. C., & Christensen, A. (2003). Who's dragging their feet? Husbands and

wives seeking marital therapy. Journal of Marital and Family Therapy, 29(2), 165-177. MFT WEBSITES 81

Doss, B. D., Mitchell, A., Georgia, E. J., Biesen, J. N., & Rowe, L. S. (2015). Improvements in

closeness, communication, and psychological distress mediate effects of couple therapy

for veterans. Journal of consulting and clinical psychology, 83(2), 405.

Doss, B. D., Simpson, L. E., & Christensen, A. (2004). Why do Couples Seek Marital Therapy?

Professional Psychology: Research and Practice, 35(6), 608-614. doi:10/1037/0735-

7028.35.6.608

Downes, P. K. (2007). Creating a practice website. British Dental Journal, 202(10), 597-604.

Duberstein, P. R., Ward, E. A., Chaudron, L. H., He, H., Toth, S. L., Wang, W., ... & Talbot, N.

L. (2018). Effectiveness of interpersonal psychotherapy-trauma for depressed women

with childhood abuse histories. Journal of consulting and clinical psychology, 86(10),

868.

Durusoy, R., Hassoy, H., & Karababa, A. O. (2013). Adolescents’ risk perceptions on mobile

phones and their base stations, their trust to authorities and incivility in using mobile

phones: A cross-sectional survey on 2240 high school students in Izmir, Turkey.

Environmental Health: A Global Access Science Source, 12(1), 1-10. doi:10.1186/1476-

069X-12-10

Edwards, M. R. (2009). An integrative review of employer branding and OB theory. Personnel

review, 39(1), 5-23.

Ekbia, H. R. (2009). Digital artifacts as quasi‐objects: Qualification, mediation, and

materiality. Journal of the American Society for Information Science and

Technology, 60(12), 2554-2566.

Elliott, K. P., Westmacott, R., Hunsley, J., Rumstein‐McKean, O., & Best, M. (2015). The

process of seeking psychotherapy and its impact on therapy expectations and MFT WEBSITES 82

experiences. Clinical psychology & psychotherapy, 22(5), 399-408.

doi:10.1002/cpp.1900

Elo, S., & Kyngäs, H. (2008). The qualitative content analysis process. Journal of advanced

nursing, 62(1), 107-115.

Evertsz, F. B., Sprangers, M. A. G., Sitnikova, K., Stokkers, P. C. F., Ponsioen, C. Y.,

Bartelsman, J. F. W. M., …Burger, H. (2017). Effectiveness of Cognitive Behavioral

Therapy on Quality of Life, Anxiety, and Depressive Symptoms among Patients with

Inflammatory Bowel Disease: A Multicenter Randomized Controlled Trial. Journal of

Consulting and Clinical Psychology, 85(9), 918-925. doi:10.1037/ccp0000227

Fletcher, G., & Light, B. (2007). Going offline: An exploratory cultural artifact analysis of an

internet dating site's development trajectories. International Journal of Information

Management, 27(6), 422-431.

Fox, S., & Jones, S. (2009). Depression, Anxiety, Stress or Mental Health Issues. PewResearch.

Retrieved from http://www.pewinternet.org/2009/06/11/depression-anxiety-stress-or-

mental-health-issues/

Francis, J. W. P. M. E., & Booth, R. J. (1993). Linguistic Inquiry and Word Count. Technical

Report. Technical Report, Dallas, TX: Southern Methodist University.

Franco, G. E. (2015). Supervision and MFT burnout: overcoming the challenges therapists face

in the workplace. Frontiers in psychology, 6, 1644.

Fugate, M., Landis, L., Riordan, K., Naureckas, S., & Engel, B. (2005). Barriers to domestic

violence help seeking: Implications for intervention. Violence against women, 11(3), 290-

310. MFT WEBSITES 83

Fürsich, E. (2009). In defense of textual analysis: Restoring a challenged method for journalism

and media studies. Journalism studies, 10(2), 238-252.

Gilchrist, L. A., & Stringer, M. (1992). Marketing counseling: Guidelines for training and

practice. Counselor Education and Supervision, 31(3), 154-162. doi:10.1002/j.1556-

6978.1992.tb00156.x

Gattis, K. S., Simpson, L. E., & Christensen, A. (2008). What about the kids? Parenting and

child adjustment in the context of couple therapy. Journal of Family Psychology, 22(6),

833-842. doi:10.1037/a0013713

Gehrke, D., & Turban, E. (1999, January). Determinants of successful website design: relative

importance and recommendations for effectiveness. In Proceedings of the 32nd Annual

Hawaii International Conference on Systems Sciences. 1999. HICSS-32. Abstracts and

CD-ROM of Full Papers (pp. 8-pp). IEEE.

Gilbert, P. (2009). Introducing compassion-focused therapy. Advances in psychiatric

treatment, 15(3), 199-208.

Goding, M. (2005). Strategic planning and public mental health services. Australasian

Psychiatry, 13(2), 116-119. doi:10.1080/j.1440-1665.2005.02172.x

Gombeski Jr, W. R., Martin, B., & Britt, J. (2015). Marketing-Stimulated Word-of-Mouth: A

Channel for Growing Demand. Health marketing quarterly, 32(3), 289-296.

Gottschalk, L., & Bechtel, R. (2007). Psychiatric content and diagnosis: The PCAD 3. Brighton,

MI: GB Software.

Greenbaum, P. E., Wang, W., Henderson, C. E., Kan, L., Hall, K., Dakof, G. A., & Liddle, H. A.

(2015). Gender and ethnicity as moderators: Integrative data analysis of multidimensional

family therapy randomized clinical trials. Journal of Family Psychology, 29(6), 919-930. MFT WEBSITES 84

Halford, W. K., Pepping, C. A., & Petch, J. (2016). The gap between couple therapy research

efficacy and practice effectiveness. Journal of Marital and Family Therapy, 42(1), 32-44.

doi:10.1111/jmft.12120

Hall, T. L. (2012). Working With Military Families. In Family Therapy Review: Contrasting

Contemporary Models (pp. 282-284). Routledge.

Hamzah, Z. L., Alwi, S. F. S., & Othman, M. N. (2014). Designing corporate brand experience

in an online context: A qualitative insight. Journal of Business Research, 67(11), 2299-

2310.

Harris, F., & De Chernatony, L. (2001). Corporate branding and corporate brand

performance. European Journal of marketing, 35(3/4), 441-456.

Hartmann, P., & Apaolaza-Ibáñez, V. (2012). Consumer attitude and purchase intention toward

green energy brands: The roles of psychological benefits and environmental

concern. Journal of business Research, 65(9), 1254-1263.

Hartmann, P., Apaolaza Ibáñez, V., & Forcada Sainz, F. J. (2005). Green branding effects on

attitude: functional versus emotional positioning strategies. Marketing Intelligence &

Planning, 23(1), 9-29.

Hausman, A. V., & Siekpe, J. S. (2009). The effect of web interface features on consumer online

purchase intentions. Journal of Business Research, 62(1), 5-13.

Hayes, A. M., & Feldman, G. (2004). Clarifying the construct of mindfulness in the context of

emotion regulation and the process of change in therapy. Clinical Psychology: science

and practice, 11(3), 255-262. doi:10.1093/clipsy/bph080 MFT WEBSITES 85

Hazelrigg, M., Cooper, H. M., & Borduin, C. M. (1987). Evaluating the effectiveness of family

therapies: An integrative review and analysis. Psychological Bulletin, 101(3), 428-442.

doi:10.1037/0033-2909.101.3.428

Henretty, J. R., & Levitt, H. M. (2010). The role of therapist self-disclosure in psychotherapy: A

qualitative review. Clinical psychology review, 30(1), 63-77.

Hill, C. E., & Knox, S. (2001). Self-disclosure. Psychotherapy: Theory, Research, Practice,

Training, 38(4), 413.

Hines-Martin, V., Malone, M., Kim, S., & Brown-Piper, A. (2003). Barriers to mental health

care access in an African American population. Issues in Mental Health Nursing, 24(3),

237-256. doi:10.1080/01612840305281

Horrigan, J. B. (2008). The Internet and Consumer Choice. PewResearch. Retrieved from

https://www.pewinternet.org/2008/05/18/the-internet-and-consumer-choice/

Horvath, A. O., Del Re, A. C., Flückiger, C., & Symonds, D. (2011). Alliance in individual

psychotherapy. Psychotherapy, 48(1), 9-16.

doi:10.1093/acprof:oso/9780199737208.003.0002

Huang, C. L., Chung, C. K., Hui, N., Lin, Y. C., Seih, Y. T., Lam, B. C., ... & Pennebaker, J. W.

(2012). The development of the Chinese linguistic inquiry and word count

dictionary. Chinese Journal of Psychology.

Internet World Stats. (2019). Usage and Population Statistics. Miniwatts Marketing Group.

Retrieved from https://www.internetworldstats.com/stats.htm

Jones, A. (2006). College clicks: Websites grow as tool to help students choose a

school. Journal-Constitution, 1B. MFT WEBSITES 86

Jones, D. B. (2001). Marketing psychological services: Using client problem and solution

perceptions to design help offering promotional appeals. Psychology & Marketing, 18(3),

261-279. doi:10.1002/15206793(200103)18:3<261::AID-MAR1008>3.0.C0;2-7

Kahn, J. H., Tobin, R. M., Massey, A. E., & Anderson, J. A. (2007). Measuring emotional

expression with the Linguistic Inquiry and Word Count. The American journal of

psychology, 263-286.

Kazdin, A. E., Marciano, P. L., & Whitley, M. K. (2005). The therapeutic alliance in cognitive-

behavioral treatment of children referred for oppositional, aggressive, and antisocial

behavior. Journal of Consulting and Clinical Psychology, 73(4), 726-730.

doi:10.1037/0022-006X.73.4.726

Keller, K. L. (2009). Building strong brands in a modern marketing communications

environment. Journal of marketing communications, 15(2-3), 139-155.

Kim, I., & Kuljis, J. (2010). Applying content analysis to web-based content. Journal of

Computing and Information Technology, 18(4), 369-375.

Klaus, P. (2013). The case of Amazon. com: towards a conceptual framework of online customer

service experience (OCSE) using the emerging consensus technique (ECT). Journal of

Services Marketing, 27(6), 443-457.

Knapp, S., & VandeCreek, L. (2008). The ethics of advertising, billing, and finances in

psychotherapy. Journal of clinical psychology, 64(5), 613-625.

Koehler, W. (1999). An analysis of web page and web site constancy and permanence. Journal

of the American Society for Information Science, 50(2), 162-180.

Kopp, R. R. (2013). Metaphor therapy: Using client generated metaphors in psychotherapy.

Routledge. MFT WEBSITES 87

Kozinets, R. V. (2002). The field behind the screen: Using netnography for marketing research in

online communities. Journal of marketing research, 39(1), 61-72.

Kwak, D. H., & Kang, J. H. (2009). Symbolic purchase in sport: the roles of self-image

congruence and perceived quality. Management Decision, 47(1), 85-99.

Labrecque, L. I., Markos, E., & Milne, G. R. (2011). Online personal branding: Processes,

challenges, and implications. Journal of interactive marketing, 25(1), 37-50.

Landefeld, C. S., & Steinman, M. A. (2009). The Neurontin legacy--marketing through

misinformation and manipulation. New England Journal of Medicine, 360(2), 103.

Lannin, D. G., Vogel, D. L., & Heath, P. J. (2017). Can reflecting on personal values online

increase positive beliefs about counseling?. Journal of counseling psychology, 64(3),

261-268. doi:10.1037/cou0000201

Liang, B., Goodman, L., Tummala-Narra, P., & Weintraub, S. (2005). A theoretical framework

for understanding help‐seeking processes among survivors of intimate partner

violence. American journal of community psychology, 36(1-2), 71-84.

doi:10.1007/s10464-005-6233-6

Lilliengren, P., Johansson, R., Town, J. M., Kisely, S., & Abbass, A. (2017). Intensive Short‐

Term Dynamic Psychotherapy for generalized anxiety disorder: A pilot effectiveness and

process‐outcome study. Clinical psychology & psychotherapy, 24(6), 1313-1321.

Loughran, T., & McDonald, B. (2011). When is a liability not a liability? Textual analysis,

dictionaries, and 10‐Ks. The Journal of Finance, 66(1), 35-65.

Lundblad, A. M., & Hansson, K. (2006). Couples therapy: effectiveness of treatment and long‐

term follow‐up. Journal of family therapy, 28(2), 136-152.

Lyman, P., & Kahle, B. (1998). Archiving digital cultural artifacts. D-lib Magazine, 4(7), 1-12. MFT WEBSITES 88

Malär, L., Krohmer, H., Hoyer, W. D., & Nyffenegger, B. (2011). Emotional brand attachment

and brand personality: The relative importance of the actual and the ideal self. Journal of

marketing, 75(4), 35-52.

Mason, M. (2010). Sample size and saturation in PhD studies using qualitative interviews.

Forum: Qualitative Social Research, 11(3), 1-15.

Masters, K. (2008). For what purpose and reasons do doctors use the Internet: a systematic

review. international journal of medical informatics, 77(1), 4-16.

Mathews, B. (1989). The use of therapist self-disclosure and its potential impact on the

therapeutic process. Journal of Human Behavior & Learning.

Mauthner, N. S., & Doucet, A. (2003). Reflexive accounts and accounts of reflexivity in

qualitative data analysis. Sociology, 37(3), 413-431.

MacFarlane, M. M. (2003). Systemic treatment of depression: An integrative approach. Journal

of family psychotherapy, 14(1), 43-61.

McMillan, S. J. (2000). The microscope and the moving target: The challenge of applying

content analysis to the World Wide Web. Journalism & Mass Communication

Quarterly, 77(1), 80-98.

Mehl, M. R., & Pennebaker, J. W. (2003). The sounds of social life: A psychometric analysis of

students' daily social environments and natural conversations. Journal of personality and

social psychology, 84(4), 857-870.

Mewburn, I., & Thomson, P. (2013). Why do academics blog? An analysis of audiences,

purposes and challenges. Studies in Higher Education, 38(8), 1105-1119.

Miles, M. B., Huberman, A. M., & Saldana, J. (2014). Qualitative data analysis: A methods

sourcebook. Sage. MFT WEBSITES 89

Molyneux, L., Holton, A., & Lewis, S. C. (2018). How journalists engage in branding on

Twitter: Individual, organizational, and institutional levels. Information, Communication

& Society, 21(10), 1386-1401.

Morely, M., & Rennison, J. (2011). Marketing occupational therapy: Everybody’s business.

British Journal of Occupational Therapy, 74(8), 406-408.

doi:10.4276/030802211X1312564371040

Motion, J. (2001). Electronic relationships: Interactivity, Internet branding and the public

sphere. Journal of Communication Management, 5(3), 217-230.

Murphy, M. J., Faulkner, R. A., & Behrens, C. (2004). The effect of therapist–client racial

similarity on client satisfaction and therapist evaluation of treatment. Contemporary

Family Therapy, 26(3), 279-292.

Murphy, S. (2000). Provision of psychotherapy services for older people. Psychiatric

Bulletin, 24(5), 181-184. doi:10.1192/pb.24.5.181

NASW. (2019). About. National Association of Social Workers. Retrieved from

https://www.socialworkers.org/About

Nelson, T. S., Chenail, R. J., Alexander, J. F., Crane, D. R., Johnson, S. M., & Schwallie, L.

(2007). The development of core competencies for the practice of marriage and family

therapy. Journal of Marital and Family Therapy, 33(4), 417-438.

Newman, M. L., Pennebaker, J. W., Berry, D. S., & Richards, J. M. (2003). Lying words:

Predicting deception from linguistic styles. Personality and social psychology

bulletin, 29(5), 665-675.

Nichols, M. (2013). Family therapy: Concepts and methods. (10th ed., pp. 76-96). Upper Saddle

River, NJ: Pearson Education, Inc. MFT WEBSITES 90

Northey Jr, W. F. (2002). Characteristics and clinical practices of marriage and family therapists:

A national survey. Journal of Marital and Family Therapy, 28(4), 487-494.

O’Cass, A., & Carlson, J. (2012). An e-retailing assessment of perceived website-service

innovativeness: Implications for website quality evaluations, trust, loyalty and word of

mouth. Australasian Marketing Journal (AMJ), 20(1), 28-36.

Olson, D. H. (2000). Circumplex model of marital and family sytems. Journal of family

therapy, 22(2), 144-167.

Orlinsky, D. E., Ronnestad, M. H., & Willutzki, U. (2004). Fifty years of psychotherapy process-

outcome research: Continuity and change. Bergin and Garfield’s handbook of

psychotherapy and behavior change, 5, 307-389.

Park, Y. A., & Gretzel, U. (2007). Success factors for destination marketing web sites: A

qualitative meta-analysis. Journal of travel research, 46(1), 46-63.

Pasley, K., Rhoden, L., Visher, E. B., & Visher, J. S. (1996). Successful Step-Family Therapy:

Clients’ perspectives. Journal of marital and family therapy, 22(3), 343-357.

Payne, K. T., & Marcus, D. K. (2008). The efficacy of group psychotherapy for older adult

clients: A meta-analysis. Group Dynamics: Theory, Research, and Practice, 12(4), 268-

278.

Pennebaker, J.W., Booth, R.J., Boyd, R.L., & Francis, M.E. (2015). Linguistic Inquiry and Word

Count: LIWC2015. Austin, TX: Pennebaker Conglomerates (www.LIWC.net).

Pennebaker, J. W., Chung, C. K. (2007). Expressive writing, emotional upheavals, and health. In:

Friedman H, Silver R, editors. Handbook of health psychology. New York: Oxford

University Press; pp. 263–284 MFT WEBSITES 91

Pennebaker, J. W., Francis, M. E., & Booth, R. J. (2001). Linguistic inquiry and word count:

LIWC 2001. Mahway: Lawrence Erlbaum Associates, 71(2001), 2001.

PewResearch (2003). Americans Search Online for Mental Health, Insurance, and Drug

Information. PewResearch. Retrieved from

http://www.pewinternet.org/2003/07/16/americans-search-online-for-mental-health-

insurance-and-drug-information/

PewResearch (2009). 61% of American Adults Look Online for Health Information.

PewResearch. Retrieved from http://www.pewinternet.org/2009/06/11/61-of-american-

adults-look-online-for-health-information/

Pitta, D. A. (1998). Marketing one-to-one and its dependence on knowledge discovery in

databases. Journal of consumer marketing, 15(5), 468-480.

Psychology Today. (2019). Find a family therapist. Sussex Publishers, LLC. Retrieved from

https://www.psychologytoday.com/us/therapists/family-

therapy?utm_source=PT_Psych_Today&utm_medium=House_Link&utm_campaign=PT

_Specialty_FTitle

Rainie, L. (2013). Cell phone ownership hits 91% of adults. PewResearchCenter, 1-6. Retrieved

from http://www.pewresearch.org/fact-tank/2013/06/06/cell-phone-ownership-hits-91-of-

adults/

Ravasi, D., & Rindova, V. (2008). Symbolic value creation. Handbook of new approaches to

organization, 270-284.

Rickwood, D. J., Deane, F. P., & Wilson, C. J. (2007). When and how do young people seek

professional help for mental health problems?. Medical journal of Australia, 187(S7),

S35-S39. MFT WEBSITES 92

Rober, P. (1999). The therapist's inner conversation in family therapy practice: Some ideas about

the self of the therapist, therapeutic impasse, and the process of reflection. Family

process, 38(2), 209-228.

Rochlen, A. B., & Hoyer, W. D. (2005). Marketing mental health to men: Theoretical and

practical considerations. Journal of Clinical Psychology, 61(6), 675-684.

doi:10.1002/jclp.20102

Rosen, D. E., Purinton, E. F., & Lloyd, S. J. (2005). Effective Web Site Design: Insight from

Information Processing. In Advanced Topics in Electronic Commerce, Volume 1 (pp. 99-

120). IGI Global.

Rossiter, J., & Bellman, S. (2012). Emotional branding pays off: How brands meet share of

requirements through bonding, companionship, and love. Journal of Advertising

Research, 52(3), 291-296.

Roy, A., & Chattopadhyay, S. P. (2010). Stealth marketing as a strategy. Business

Horizons, 53(1), 69-79.

Rude, S., Gortner, E. M., & Pennebaker, J. (2004). Language use of depressed and depression-

vulnerable college students. Cognition & Emotion, 18(8), 1121-1133.

Ruzgar, N. S. (2005). A Research on the Purpose of Internet Usage and Learning via

Internet. Turkish Online Journal of Educational Technology-TOJET, 4(4), 27-32.

Saldaña, J. (2015). The coding manual for qualitative researchers. Sage.

Saloheimo, H. P., Markowitz, J., Saloheimo, T. H., Laitinen, J. J., Sundell, J., Huttunen, M. O.,

... & Katila, H. O. (2016). Psychotherapy effectiveness for major depression: a

randomized trial in a Finnish community. BMC psychiatry, 16(1), 131-139.

Schmitt, B. (1999). Experiential marketing. Journal of marketing management, 15(1-3), 53-67. MFT WEBSITES 93

Schofield, C. A., Weis, H., Ponzini, G., & McHugh, R. K. (2017). Improving perceptions of

cognitive-behavioral therapy with brief website exposure: Does neuroscientific allure

impact attitudes?. Journal of behavior therapy and experimental psychiatry, 57, 53-61.

Sexton, H., Littauer, H., Sexton, A., & Tømmerås, E. (2005). Building an alliance: Early therapy

process and the client–therapist connection. Psychotherapy Research, 15(1-2), 103-116.

Shadish, W. R., & Baldwin, S. A. (2005). Effects of Behavioral Marital Therapy: A Meta-

Analysis of Randomized Control Trials. Journal of Consulting and Clinical Psychology,

73(1), 6-14. doi:10.1037/0022-006X.73.1.6

Shepherd, I. D. (2005). From cattle and coke to Charlie: Meeting the challenge of self marketing

and personal branding. Journal of Marketing Management, 21(5-6), 589-606.

Silva, R. V. D., & Alwi, S. F. S. (2008). Online brand attributes and online corporate brand

images. European Journal of Marketing, 42(9/10), 1039-1058.

Simmons, G. J. (2007). “i-Branding”: developing the internet as a branding tool. Marketing

Intelligence & Planning, 25(6), 544-562.

Smith, K. T. (2012). Longitudinal study of digital marketing strategies targeting

Millennials. Journal of Consumer Marketing, 29(2), 86-92.

Smith, E. C., & Grawe, K. (2003). What makes psychotherapy sessions productive? A new

approach to bridging the gap between process research and practice. Clinical Psychology

& Psychotherapy: An International Journal of Theory & Practice, 10(5), 275-285.

Sommerfeldt, E. J., Kent, M. L., & Taylor, M. (2012). Activist practitioner perspectives of

website public relations: Why aren’t activist websites fulfilling the dialogic

promise?. Public Relations Review, 38(2), 303-312. MFT WEBSITES 94

Southam-Gerow, M. A., & Kendall, P. C. (2002). Emotion regulation and understanding:

Implications for child psychopathology and therapy. Clinical psychology review, 22(2),

189-222. doi:10.106/s0272-7358(01)00087-3

Sprenkle, D. H. (2003). Effectiveness research in marriage and family therapy:

Introduction. Journal of Marital and Family Therapy, 29(1), 85-96.

Sprenkle, D. H., Blow, A. J., & Dickey, M. H. (1999). Common factors and other nontechnique

variables in marriage and family therapy.

Stemler, S. (2001). An overview of content analysis. Practical assessment, research &

evaluation, 7(17), 137-146.

Supiano, K. P., & Luptak, M. (2013). Complicated grief in older adults: A randomized controlled

trial of complicated grief group therapy. The Gerontologist, 54(5), 840-856.

doi:10.1093/geront/gnt076

Sutherland, J., Duke, L., & Abernethy, A. (2004). A model of marketing information flow: What

creatives obtain and want to know from clients. Journal of Advertising, 33(4), 39-52.

Swank, J. M., & Smith-Adcock, S. (2018). On-task behavior of children with attention-

deficit/hyperactivity disorder: Examining treatment effectiveness of play therapy

interventions. International Journal of Play Therapy, 27(4), 187-197.

Tambling, R. B. (2012). A literature review of therapeutic expectancy effects. Contemporary

Family Therapy, 34(3), 402-415.

Tambling, R. R. (2019). A Critical Evaluation of Motivation to Change Conceptualization,

Measurement, and Utility in Counseling and Psychotherapy. The Family Journal, 27(2),

232-238. doi:10.1177/1066480719833399. MFT WEBSITES 95

Tambling, R. B., & Johnson, L. N. (2010). Client expectations about couple therapy. The

American Journal of Family Therapy, 38(4), 322-333.

Tambling, R. B., Wong, A. G., & Anderson, S. R. (2014). Expectations about couple therapy: A

qualitative investigation. The American Journal of Family Therapy, 42(1), 29-41.

Tang, T. (2011). Marketing higher education across borders: a cross-cultural analysis of

university websites in the US and China. Chinese Journal of Communication, 4(4), 417-

429.

Tausczik, Y. R., & Pennebaker, J. W. (2010). The psychological meaning of words: LIWC and

computerized text analysis methods. Journal of language and social psychology, 29(1),

24-54.

Tentoni, S. C. (1997). A marketing technique to increase visibility and use of health center

counseling services. Journal of American College Health, 46(2), 93-95.

doi:10.1080/07448489709595593

Thomas, D. R. (2006). A general inductive approach for analyzing qualitative evaluation

data. American journal of evaluation, 27(2), 237-246.

Thompson, C. J., Rindfleisch, A., & Arsel, Z. (2006). Emotional branding and the strategic value

of the doppelgänger brand image. Journal of marketing, 70(1), 50-64.

Tiago, M. T. P. M. B., & Veríssimo, J. M. C. (2014). Digital marketing and social media: Why

bother?. Business horizons, 57(6), 703-708.

Topolinski, S., Zürn, M., & Schneider, I. K. (2015). What's in and what's out in branding? A

novel articulation effect for brand names. Frontiers in Psychology, 6, 1-10.

Tullis, T. S., & Stetson, J. N. (2004, June). A comparison of questionnaires for assessing website

usability. In Usability professional association conference (Vol. 1). MFT WEBSITES 96

United States Census Bureau. (2012). Computer and Internet trends in America. United States

Census Bureau, 1. Retrieved from

https://www.census.gov/hhes/computer/files/2012/Computer_Use_Infographic_FINAL.p

df

Vaismoradi, M., Turunen, H., & Bondas, T. (2013). Content analysis and thematic analysis:

Implications for conducting a qualitative descriptive study. Nursing & health

sciences, 15(3), 398-405.

Vall, B., Seikkula, J., Laitila, A., & Holma, J. (2016). Dominance and dialogue in couple therapy

for psychological intimate partner violence. Contemporary Family Therapy: An

International Journal, 38(2), 223-232. doi:10.1007/s10591-015-9367-1

Vásquez, C., Sergi, V., & Cordelier, B. (2013). From being branded to doing branding: Studying

representation practices from a communication-centered approach. Scandinavian Journal

of Management, 29(2), 135-146.

Venner, K. L., Greenfield, B. L., Vicuña, B., Muñoz, R., Bhatt, S., & O'keefe, V. (2012). “I'm

not one of them”: Barriers to help-seeking among American Indians with alcohol

dependence. Cultural Diversity and Ethnic Minority Psychology, 18(4), 352.

Waxman, K. T. (1998). Marketing your skills outside the hospital walls. Nursing

management, 29(8), 48-51. doi:10.1097/0000647-199808000-00017

Werner-Wilson, R. J., Michaels, M. L., Thomas, S. G., & Thiesen, A. M. (2003). Influence of

therapist behaviors on therapeutic alliance. Contemporary Family Therapy, 25(4), 381-

390.

White, M. D., & Marsh, E. E. (2006). Content analysis: A flexible methodology. Library

trends, 55(1), 22-45. MFT WEBSITES 97

Wolitzky-Taylor, K., Krull, J., Rawson, R., Roy-Byrne, P., Ries, R., & Craske, M. G. (2018).

Randomized clinical trial evaluating the preliminary effectiveness of an integrated

anxiety disorder treatment in substance use disorder specialty clinics. Journal of

consulting and clinical psychology, 86(1), 81-88.

Yoo, H., Bartle-Haring, S., & Gangamma, R. (2014). Predicting premature termination with

alliance at sessions 1 and 3: An exploratory study. Journal of Family Therapy, 38(1), 5-

17. doi:10.1111/1467-6427.12031