The Impact of Fictional Television Portrayals of Psychotherapy on Viewers’ Expectations of Therapy, Attitudes Toward Seeking Treatment, And

The Impact of Fictional Television Portrayals of Psychotherapy

on Viewers’ Expectations of Therapy, Attitudes Toward Seeking Treatment, and

Induction into Dramatic Narratives.

A dissertation presented to

the faculty of

the College of Arts and Sciences of Ohio University

In partial fulfillment

of the requirements for the degree

Doctor of Philosophy

Troy A. Robison

August 2013

This dissertation titled

The Impact of Fictional Television Portrayals of Psychotherapy on Viewers’ Expectations of Therapy, Attitudes Toward Seeking Treatment, and

Induction into Dramatic Narratives.

TROY A. ROBISON

has been approved for

the Department of Psychology

and the College of Arts and Sciences by

Benjamin M. Ogles

Professor of Psychology

John P. Garske

Professor Emeritus of Psychology

Robert Frank

Dean, College of Arts and Sciences 3

ABSTRACT

ROBISON, TROY A., Ph.D., August 2013, Psychology

The Impact of Fictional Television Portrayals of Psychotherapy on Viewers’

Expectations of Therapy, Attitudes Toward Seeking Treatment, and Induction into

Dramatic Narratives.

Directors of Dissertation: Benjamin M. Ogles & John P. Garske

Many have speculated that portrayals of psychotherapy in the popular media can influence viewer’s expectations, attitudes, and intentions to seek therapy. Unfortunately, these claims are rarely (if ever) validated by research studies using sound, controlled methodology. Similarly, no studies have examined therapy portrayals in connection to theories of media persuasion. The purpose of this study was to empirically investigate the impact of fictional television portrayals of psychotherapy on the viewers’ beliefs about psychotherapeutic treatment. This study experimentally explored the effects of therapy portrayals on viewers’ expectations of treatment, attitudes about seeking psychotherapy, and explored the relationship between psychological distress and theoretically supported variables of media persuasion such as transportation and narrative engagement. The results of the study indicate that media portrayals influence viewers’ beliefs about seeking psychotherapy and characteristics of the therapist. A relationship between psychological distress and induction into dramatic media narratives was not found, however perceived realism of the portrayals was highly related to narrative induction.

DEDICATION

This dissertation is dedicated to my parents, Allen and Ilona Robison, and all of the many

family and friends who have supported me while working toward my degree.

ACKNOWLEDGMENTS

Many thanks go out to all those who provided assistance to me, not only on this project but also throughout my graduate training. This includes my graduate advisor

Benjamin M. Ogles and also John P. Garske who served as the chair for this dissertation.

I’d also like to thank those who offered input and assistance with the project, including

Tim Anderson, Debbie Thurneck, Akil Houston, and especially Dori Bloom. Finally, a great thanks to Christine Gidycz, my many clinical supervisors, and the faculty and staff of the Psychology Department for the training, teaching, help, and patience they have provided during my years of graduate training at Ohio University.

TABLE OF CONTENTS

Page

Abstract...... 3 Dedication...... 4 Acknowledgments ...... 5 List of Tables ...... 8 Introduction...... 9 Portrayal of Psychotherapy in the Media...... 11 Literature Review on Media Portrayals of Psychotherapy ...... 12 Expectations of Psychotherapy and Treatment Seeking...... 13 Research Findings on Expectations...... 14 Research Findings on Seeking Behavior...... 15 Media Impact and Persuasion ...... 16 Theoretical models of persuasion...... 16 Transportation & narrative engagement...... 18 Prior Research on Media Portrayals of Psychotherapy...... 19 Summary of Concepts...... 24 Hypotheses...... 26 Method...... 28 Participants...... 28 Materials ...... 28 Measures ...... 31 Procedure ...... 36 Results...... 39 Main Hypotheses ...... 40 Post-Hoc Examinations...... 44 Discussion...... 47 Limitations & Directions for Future Research...... 52 Conclusion ...... 55 References...... 56 7

Appendix A: Expectations About Counseling – Brief Form...... 79 Appendix B: Thoughts About Psychotherapy Survey...... 85 Appendix C: Attitudes Toward Seeking Professional Psychological Help...... 87 Appendix D: Intentions to Seek Counseling Inventory...... 88 Appendix E: Stigma Scale for Receiving Psychological Help...... 89 Appendix F: Transportation Scale ...... 90 Appendix G: Narrative Engagement Scale...... 91 Appendix H: Self-Survey ...... 92 Appendix I: Demographics Questionnaire ...... 93 Appendix J: Consent Form ...... 94 Appendix K: Debriefing Form...... 96 Appendix L: Study Instructions...... 97

LIST OF TABLES

Page

Table 1: Post Exposure Means (SD) for Dependent Variables by Condition ...... 75 Table 2: Contrasts Between Means (SD)...... 76 Table 3: Correlations Between Constructs ...... 77 Table 4: Hypotheses and Results ...... 78

INTRODUCTION

“Therapy can be really boring. Unless it’s on TV, then it can be crazy, funny, scary, and dramatic.” - Matthew Gilbert (2010), television critic for the Boston Globe

For over forty years it has been assumed that beliefs about therapy in the general population are at least partially based on the way psychotherapy is portrayed in the media

(Kadushin, 1969). This is not surprising, as television series like The Bob Newhart Show

(Zinberg, 1972), The Sopranos (Chase, 1999), and more recently In Treatment (Garcia,

2008), have captivated both public and professional audiences alike. Because of television’s power to communicate the picture of a profession to the public (Cialdini;

1997), many have assumed these popular portrayals could substantially impact the image of the psychotherapy profession (APA, 1986; Gabbard & Gabbard, 1999; Kadushin,

1969, Wedding & Niemic, 2003). Their fears are not without merit, as it has clearly been shown that television shapes our reality, attitudes, and perceptions by influencing the images we see and the stories we consume (Gerbner, Gross, Morgan, Signorelli, &

Shanahan, 2002; Moyer-Guse & Nabi, 2010; Shanahan & Morgan, 1999).

The potential impact of media’s influence could indeed be vast. Psychotherapy research has clearly established that a client’s perceptions of therapy are crucial to both treatment success and where they choose to turn for help (Furnham, Pereira, & Rawles,

2001). Perhaps this is why many people with inaccurate expectations are afraid to seek therapy (Gonzalez, Tinsley, & Kreuder, 2002) or perceive psychotherapy as a useless treatment (Janda, 1998; Jorm et al. 1997). The number of people utilizing therapy services has also steadily declined in the last decade, prompting the APA to call for 10 advocacy efforts in media that highlight the effectiveness of therapeutic treatment (Clay,

2011, Olfson & Marcus, 2010).

The influence of media is pervasive, with television watching at an all-time high and rising. Today’s “virtual generation” spends an average of 5 hours a day watching television, learning more from media than any who have come before (Smith, 2009; The

Nielsen Company, 2009). College students alone spend approximately 12 hours a day engaged with media (Alloy College Explorer Survey, 2009). Heavy viewers are consistently more likely to perceive mainstream media messages as more factual, credible, and normal than they are (Gerbner, Gross, Morgan, Signorelli, & Shanahan,

2002; Morgan & Shanahan, 2010; Morgan, Shanahan, & Signorelli, 2009; Nabi &

Sullivan, 2001; Signorelli, 1991).

One of the most frequently portrayed professions on television is the psychotherapist, which is not surprising, given that the therapy dynamic is a particularly useful tool for advancing plot. Unfortunately, these on-screen depictions are also what many people turn to and draw upon for information about psychotherapy when their personal experience with treatment is limited (Gabbard 2001; Hodson, 2001, Jorm,

2000). Schultz (2005) believes that because many never encounter psychotherapy personally, it is more stigmatized from media exposure than other professions with more frequent public interaction. This is a troubling concern, as research clearly shows that increased exposure to television is positively correlated with both negative attitudes toward psychotherapy and personal unhappiness (Borenstein, 1992; Bram, 1997;

Granello, 2000; Jorm, 2000; Lopez, 1991; Robinson et al, 2008; Vogel, 2005). This could 11 indicate that many who might benefit from therapy are also more susceptible to these portrayals of treatment.

This study was conducted to investigate how media portrayals of psychotherapy influence pretreatment client expectations and treatment seeking attitudes. Because these beliefs exist before someone decides to schedule an appointment or walk through the door of a psychotherapist’s office, they are often excluded from research and warrant greater examination (Dew & Bickman, 2005). Before describing methodology, results, and findings, a brief history of therapy’s portrayal in fictional media will be reviewed, along with the relevant research on psychotherapy expectations, treatment seeking, and theoretical models of media persuasion.

Portrayal of Psychotherapy in the Media

Concern about the impact of fictional psychotherapy portrayals is warranted, as they are rife with ridiculous, unethical, and even malicious depictions of treatment

(Gabbard & Gabbard, 1999; Hyler, 1988; Kadushan, 1969). Indeed, the picture of therapy painted by popular media is rarely flattering; often showing therapists as incompetent, ineffective, and manipulative figures who typically cause more harm than good to befall their clients (Grinfield, 1998; Lehmann, 2002; Von Sydow & Reimer, 1998).

Misconceived expectations of psychotherapy could certainly result from such inaccuracies. Some have even argued these media depictions directly reflect society’s beliefs about psychotherapy and that individuals form their image of treatment from these portrayals, making it irresponsible not to address them (Gabbard, 2001; Hyler, 1988). The

APA has heeded such warnings and issued press releases on television therapy’s lack of 12 ethics (APA, 2008). The Media Watch Committee was also formed, tasked with commenting on, counteracting, and rewarding portrayals of psychotherapy in film and television (Schultz, 2005).

Literature Review on Media Portrayals of Psychotherapy

Past literature on media portrayals of therapy has typically focused on stereotypes of exaggerated therapeutic extremes, ranging from power abusing villains to the cathartic breakthroughs of miracle workers (Gordon, 1994). Schneider’s (1987) classifications, Dr.

Wonderful, Dr. Evil, and Dr. Dippy, are the most widely used categorical types, with notable additions, such as the Wounded Healer and Dr. Sexy, being labeled by others over the years (Schultz, 1998; 2005, Hodson, 2001; Pies, 2001).

Psychologists have had an array of opinions about the impact of such portrayals.

Some believe they foster, “a sense of compassion for the misguided professional”

(Orchowski, Spickard, and McNamara, 2006, p.508) and others see them as, “myths that reinforce public fears and ambivalence about psychotherapy” (Schultz, 2005, p.19).

Gabbard (1985) believes that psychotherapy has “suffered more” from these media portrayals than any of its critics or detractors (p. 171). Unfortunately, all of these speculations share a considerable absence of proof. Schultz (2007) clarifies that there is,

“scant empirical evidence examining their effect upon public opinion” (p.9). In their extensive review of the available research on popular media portrayals of psychotherapy,

Pirkis, Blood, Francis, and McCallum (2006) found, “no studies systematically examining the portrayal of on-screen psychotherapy” (p.12). 13

Due to the paucity of empirical evidence to substantiate claims about the impact of media portrayals of therapy, further investigation is necessary. Their most worrisome effect is potentially on those who could benefit from therapy but choose not to due to the impact of negative, inaccurate, fictional portrayals of psychotherapy. Because media has been shown to influence the perceived risks and benefits of engaging in therapeutic treatment, these portrayals likely affect both expectations about therapy and attitudes toward seeking therapy in the first place (Bram, 1997; Robison & Ogles, 2009; Vogel,

Gentile, & Kaplan, 2008).

Expectations of Psychotherapy and Treatment Seeking

Researchers have examined client expectations of therapy for over fifty years, typically considering them fundamental to its success (Frank, 1961, Price & Price, 1999;

Rosenthal & Frank, 1956). Client expectations have previously been considered “static” variables that were impermeable to change, but more recent studies have shown they can be improved from exposure to educational media (Gonzalez, Tinsley, & Kruder, 2002;

Swift & Callahan, 2011; Whitaker, Philipps, & Toker, 2004). These findings reveal that there is limited understanding of how people acquire pretreatment expectations

(Patterson, 2010). Although multiple studies have examined approaches for changing client expectations (Kirsch, 1990; Frank & Frank, 1991; Nock & Kazdin, 2001; Dew &

Bickman, 2005), all of these require that individuals have positive enough expectations to enter therapy in the first place. They do not address those formed prior to treatment, such as those obtained by media portrayals of treatment. 14

Because expectations of therapy have been investigated in diverse ways, it is useful to clearly define what constitutes “client expectations.” Generally, these are the client’s beliefs about treatment procedures, the therapist’s role in facilitating these procedures, and the duration of therapy (Garfield, 1994). When coming to therapy for the first time, a client becomes engaged in the “patient” role, which is counterbalanced by the role of “therapist.” These roles, and the expectations associated with them, influence the course of therapy (Orlinsky, Ronnestad, & Willutzki, 2004). Expectations can be further conceptualized as pretreatment characteristics of the client, including their anticipation of treatment, outcomes, intervention delivery, and therapist behavior (Dew & Bickman,

2005; Nock & Kazdin, 2001). Expectations should be differentiated from motivation for treatment, which could be different than beliefs of what will occur or benefits to be gained from treatment (Arnkoff, Glass, & Shapiro, 2002).

Research Findings on Expectations

In recent years, there has been a resurgence of research examining the influence of client expectations on treatment outcome. (Arnkoff, Glass, & Shapiro, 2002;

Delsignore & Schyder, 2007; Dew & Bickman, 2005; Greenburg, Constantino, & Bruce,

2006; Orlinsky, Ronnestad & Willutski, 2004). Such appropriately termed “outcome expectations” are the client’s beliefs regarding the degree that therapy will lead to improvement in their lives, or their prognostic beliefs about the consequences of engaging in treatment (Goldstein, 1962). A modest but direct relationship between client expectations and clinical improvement has consistently been found (Delsignore &

Schnyder, 2007; Dew & Bickman, 2005). Early treatment client expectations are usually 15 considered small but significant predictors of outcome that influence the effectiveness and credibility of interventions (Schulte, 2008).

Research on client expectations has also addressed the therapeutic working alliance, which is a reliable mediator between expectations and outcome (Dew &

Bickman, 2005; Holt & Heimburg, 1990; Joyce & Piper, 1998; Meyer, et al., 2002; Rizvi, et al, 2000). The working alliance is the interpersonal bond between the client and therapist, as well as their agreement on the goals and tasks occurring in therapy (Bordin,

1979). The alliance is a consistent predictor of outcome in therapy (Horvath & Bedi,

2002; Martin, Garske, & Davis, 2000). Client expectations have been shown to be the single best predictor of the quality of the therapeutic alliance, and those who come to therapy with initially positive expectations also have stronger bonds with their therapist and improved treatment outcomes (Arnkoff, Glass, & Shapiro, 2002; Constantino,

Arnkoff, Glass, Ametrano, & Smith, 2011; Rizvi et al, 2000).

Research Findings on Seeking Behavior

Overall trends from the last five years indicate a decline in the number of people seeking therapy services and show that almost one-third (24 million in the U.S.) of those who meet criteria for a mental disorder do not receive treatment (Andrews, Issakidis, &

Carter, 2001; Clay, 2011; Kushner & Sher, 1991; Olfson & Marcus, 2010). This is despite evidence that the majority of therapy consumers benefit to some degree (Hollon,

Stewart, & Strunk, 2006; Imel, McKay, Malterer, & Wampold, 2008; Wampold, 2001).

Studies have shown that pretreatment expectations contribute to non-utilization of psychological services (Furnham, 2001; Kushner & Sher, 1991; Tinsley, Bowman, & 16

Barich, 1993; Vogel & Wester, 2003; Vogel, Wester, Wei, & Boysen, 2005). Some believe this represents a shift in the public’s perception of therapy, possibly because of the way it is portrayed in popular media (Morell & Metzel, 2005).

Media Impact and Persuasion

The general consensus from decades of empirical investigation is that frequent and direct exposure to the unavoidable and recurrent messages of media cultivates our long-term conception of reality (Bryant & Miron, 2004; Gerbner, Gross, Morgan,

Signorelli, & Shanahan, 2002; Morgan & Shanahan, 2010). This research has produced notable findings regarding beliefs about violence, marriage, career choice, environmental issues, family structure, political views, and healthcare (Gerbner & Gross, 1976; Gerbner et al. 1982; Morgan, Leggett, & Shanahan, 1999; Segrin & Nabi, 2002; Shanahan,

Morgan, & Stenbjerre, 1997; Signorelli, 1991; Signorelli, 1993). Television in particular has been shown to play a role in developing our beliefs about stereotypes, health, science, religion, and politics among other areas (Gerbner & Gross, 1976; Gerbner, Gross,

Morgan, & Signorelli, 1986, Shanahan & Morgan, 1999).

Theoretical Models of Persuasion

Several theories have attempted to illustrate how media can produce attitude change and persuasion (see Petty, Priester, & Brinol, 2002 for a review). Petty and

Cacioppo’s (1986) Elaboration Likelihood Model (ELM) proposes that this influence occurs from one’s evaluation (or elaboration) of presented information through two routes: the central route, with active consideration and attention by the perceiver, or the peripheral route, where individuals are swayed by the likeability or attractiveness of the 17 message through simple cues. Experts tend to engage in higher levels of elaboration, while novices respond to more literal cues (Lein, 2001; Maheswaren & Sternthal, 1999).

Lay viewers are also more likely to respond to simple cues in messages and are more persuaded when they have a vested interest in the material (Petty, Priester, & Brinol,

2002). This could potentially explain the level of attention paid to these psychotherapy portrayals by the profession (see Gabbard, 2001; Orchowski, Spickard, & McNamara,

2006; Shultz, 2005; Wedding & Neimic, 2003).

Most investigations of popular media’s influence favor the peripheral route of persuasion, which can be highly biased by means such as repetition, attitude, prior knowledge, and current emotional state, especially when available information is low

(Burke et al, 1988; Petty, Priester, & Brinol, 2002). The viewer’s responsiveness to material is increased when it is relatable to their experiences (Burnkrant & Unnava, 1995;

Lee et al, 1999; Meyers-Levy & Peracchio, 1995). Because of this, greater interest has recently been paid to the viewer’s experience, as their level of involvement with the content has been shown to play a crucial role in the acceptance and persuasion of media messages (Moyer-Guse & Nabi, 2010).

A more recent theory of persuasion, The Extended Elaboration Likelihood Model

(E-ELM; Slater & Rouner, 2002), replaces the level of issue involvement with audience involvement. It proposes that viewer’s engagement with the storyline evokes an emotional response and predicts persuasiveness, even if the message contradicts their previous beliefs (Green & Brock, 2000; Dal Cin, et al. 2004; Moyer-Guse, 2008).

Essentially, E-ELM and other similar theories that build from it (such as EORM; Moyer- 18

Guse, 2008) propose that the viewer’s level of involvement with the story reduces their resistance to developing counterarguments to the portrayal’s message. These more recent theories have shown that dramatic narratives can be more persuasive than real stories, making them applicable to the effects of fictional therapy portrayals (Green & Brock,

2000; Slater & Rouner, 2002; Moyer-Guse & Nabi, 2010).

Transportation & Narrative Engagement

While a dominant factor has yet to emerge that fully explains how audiences become involved in stories from media (typically referred to as narratives), one that has garnered much attention is transportation, which claims that the viewer’s immersion into a dramatic narrative creates a connection to the fictional reality (Green & Brock 2000).

Transportation is greater when it coincides with personal experience, which increases the acceptance of narrative messages while reducing resistance to its credibility (Green,

2004; Strange, 2002). It has been found to produce perceptions, beliefs, and emotions that are as strong as, and more powerful than, those from actual occurrences (Dal Cin et al.

2007; Moyer-Guse & Nabi, 2010; Slater, Rouner, & Long, 2006).

Another factor of audience involvement considered by persuasion theories is narrative engagement (Busselle & Bilandzic, 2008). Similar to transportation, this is the extent that viewers become involved in the world of the narrative. Narrative engagement occurs through several factors, including narrative understanding (how much it makes sense), attentional focus (or the lack of distraction), narrative presence (the acceptance of the narrative’s presented reality), and emotional engagement (how they affectively respond to the message) (Busselle & Bilandzic, 2009). While narrative engagement 19 corresponds to several aspects of transportation, some have argued that transportation is only one aspect of a broader and multi-dimensional construct of greater phenomenological engagement (Leavitt & Christenfield, 2011).

To understand the full impact of television portrayals of therapy, investigating the viewer’s level of involvement is crucial for discovering by what means presentations of treatment persuade and influence beliefs. No similar study has attempted to explore these factors, which may particularly apply to those who identify the most with these depictions and could benefit from psychotherapy (such as individuals who are psychologically distressed).

Prior Research on Media Portrayals of Psychotherapy

Earlier research has shown that negative attitudes toward therapists become more common as media exposure increases. Bram (1997) asked participants about their overall level of media use and then surveyed their perceptions of sexual boundary violations in therapy. He found that as media exposure increased, so did participant’s overestimation of: the frequency of sexual encounters in therapy, the number of therapists who act on sexual feelings, and the number of insulted therapists who would retaliate against their clients. Bram concluded that media exposure predicted negative beliefs of therapy in some situations.

In a more recent study, Vogel, Gentile, and Kaplan (2008) investigated the relationship between media exposure and perceived stigma related to seeking psychotherapy. They hypothesized that inaccurate media portrayals of therapy would increase stigma by influencing anticipated risks and benefits of treatment. They found 20 that greater media exposure predicted stigma by increasing the perceived risk of disclosing personal information. Vogel and colleagues concluded this likely influenced seeking behavior, as frequent media consumers also anticipated lower benefits from engaging in psychotherapy treatment.

Both of these studies had several limitations. Neither study used a control group comparison or media manipulation as would be required by more rigorous empirical standards. Moreover, they only assessed the viewer’s overall media exposure, while paying no direct attention to portrayals of therapy specifically. While they showed that media exposure influences negative perceptions, certain negative stereotypes, and negative attitudes toward seeking treatment, they do not show that therapy portrayals themselves cause these effects. In fact, only three published studies have directly looked at the impact of psychotherapy portrayals.

The earliest study examining a specific film’s impact was Domino’s (1983) investigation of how One Flew Over the Cuckoo’s Nest (Forman, 1975) influenced attitudes about mental illness. Using a pre and post-test design, researchers measured college student’s attitudes about five areas; mental health professionals, mental hospitals, the mentally ill, heredity of illness, and social aspects of mental illness. Eight months later, after the film’s release, they re-administered the same survey and asked the students if they had seen the film during this time. Participants were then divided into two groups, and one group watched a television documentary comparing the film to an actual mental institution. Domino found that those who viewed the film had more negative attitudes 21 about mental illness than those who did not. The results also showed that the documentary, which was hypothesized to counter-act the film’s impact, had no effect.

Some strengths of Domino’s (1983) study were its use of an actual portrayal and the presence of a control group for the documentary condition. However, it was limited by non-random assignment, which allowed for selection bias of those who saw the film.

The 8-month gap between measurements also allowed for extraneous variables, such as time, society, education, or other media, to influence viewers’ attitudes which made it impossible to determine the immediate impact of the film. Finally, it is important to point out that Domino only measured beliefs about mental illness, not psychotherapy specifically.

Only two studies have specifically investigated psychotherapy and media portrayals. Schill, Harsh, and Ritter (1990) measured perceptions of sexual boundary violations in psychiatric treatment after showing participants the film Lovesick

(Brickman, 1983), a comedy starring Dudley Moore as a psychoanalyst who becomes romantically involved with his patient. The researchers developed a 10-item survey that inquired about therapist’s behavior, its effect (such as sexual relationships being damaging or not), and beliefs about how often such behavior occurred. After completing this measure, participants immediately viewed the film in its entirety and again took the survey. Schill and his colleagues found that after viewing the film, participants were more likely to assume sexual relationships between analysts and patients occur and were less likely to assume these relationships are damaging. 22

Many elements of Schill, Harsh, and Ritter’s (1990) study warrant critique.

Because the survey was administered immediately prior to and directly following the film, participants were possibly primed to attend to therapist-client relationships. There was also no control condition, making it impossible to account for other variables or draw conclusions about the true impact of the portrayal itself. Finally, only one film and one type of therapist behavior was studied, making it difficult to generalize their findings to other contexts or different portrayals.

Robison and Ogles (2009) examined the impact of film portrayals of psychotherapy on expectations and seeking attitudes. To remedy the limitations of previous studies, a more rigorous experimental design was used. Prior to the study, several professional therapists rated film clips of psychotherapy that were compiled from multiple films. The clips were then classified as either positive or negative portrayals based on their polarity from these ratings. College students who had previously completed measures of their beliefs about therapy were then recruited. After being randomly assigned to treatment or control conditions, participants viewed positive or negative compilations of these clips. Afterward, their expectations, attitudes, and intentions to seek therapy were assessed using empirically validated measures.

The results of Robison and Ogles’ (2009) study showed that viewing the therapy portrayals negatively influenced participant’s beliefs about therapist’s characteristics, specifically about therapist’s professional behavior. Unexpectedly, those who viewed the positive film clips had more negative expectations than those in the control condition. 23

Those who viewed the negatively rated clips also had more concerns about seeking psychological help.

While providing empirical evidence that viewers could be influenced by portrayals of treatment, the Robison and Ogles (2009) study suffered from limitations that the current study addressed. For example, it did not incorporate theoretical concepts such as audience involvement, which provided only a limited understanding of how media influence occurs. It also did not investigate whether potential seekers of treatment were more influenced than those who are less connected to the material. The use of clipped segments also could have hindered narrative development and story context.

Finally, it is possible that a “genre effect” led to the reversed findings, as most of the positively rated clips were emotionally dramatic scenes.

In a follow up to the previous study, Robison and Ogles (2010) explored differences between the professional therapist’s ratings and those obtained from college students who rated the same clips on an identical scale. The results showed there was a significant difference between the perceptions of psychotherapy experts and novice viewers. The present study also corrected for this disparity by having students rate their own perceptions of the portrayal.

Several attempts have been made to understand how film portrayals of psychotherapy influence those who see them. While all are limited, they do contribute to a growing body of research that informs an area traditionally marred by speculation and personal opinion. This study used experimentally manipulated portrayal conditions, controlled for pre-exposure beliefs and attitudes about psychotherapy, and identified 24 specific characteristics of viewers that incorporated theoretical concepts for how such influence occurs.

Summary of Concepts

It has long been understood that individuals come to the psychotherapy with varied beliefs about what occurs. These beliefs influence whether or not one seeks treatment in the first place, the content and focus of therapy, the therapeutic alliance, and the outcome. Despite research establishing the importance of expectations during treatment, few studies have investigated how these beliefs about therapy are formed prior to someone entering treatment.

Those in the psychotherapy profession have voiced concerns about media’s depiction of psychotherapy because of the stereotyped and inaccurate way the therapeutic profession is portrayed. Many have speculated that these depictions are detrimental to both the field and potential consumers of treatment. Their concerns are reasonable, as misconceptions of therapy formed by watching these portrayals could possibly stop those who could benefit from seeking treatment. Unfortunately, limited empirical evidence exists to support such assumptions.

Recent theories of media’s influence have elaborated on the understanding of persuasion by integrating aspects of personal involvement, such as narrative engagement and transportation, allowing for better conceptualizations of how therapy portrayals influence viewers. Research has shown that media consumption and negative beliefs about therapy are correlated. However, the few studies that examined the impact of these portrayals directly suffer from methodological concerns. The current study attempted to 25 account for the limitations of earlier studies while also exploring new routes for understanding the influence of television portrayals of psychotherapy. 26

HYPOTHESES

The purpose of this study was to explore the influence of television psychotherapy portrayals on viewers’ expectations of therapy and intentions to seek treatment.

Additionally, the study also sought to explore whether those who might benefit from psychotherapy (as measured by psychological distress) had greater personal involvement with the portrayals and were thus more influenced by them as predicted by persuasion theories. Specifically, the hypotheses were:

H1: The first hypothesis examined how viewer expectations were altered following exposure to television portrayals of fictional therapy. It was hypothesized that portrayals of psychotherapy would influence expectations of therapy procedures, role behaviors, and effectiveness.

H2: Following the first hypothesis, it was also expected that those who viewed portrayals of psychotherapy would also be significantly influenced regarding their attitudes, intentions, and perceived stigma toward seeking psychological help as a viable treatment option.

H3: The third hypothesis investigated group differences based on the nature of the portrayal’s content as being either a positive or negative depiction of psychotherapy treatment. It was estimated that those viewing the positive portrayal of psychotherapy

(rated by the participant’s own report) would endorse more positive expectations of psychotherapy. Conversely, those in the negative portrayal condition would have more negative expectations of treatment. 27

H4: Similar to the previous hypothesis, it was proposed that those viewing the portrayal of psychotherapy rated as positive would endorse more favorable attitudes toward seeking psychotherapy services. Those viewing the negatively rated portrayal of psychotherapy were predicted to have more negative attitudes about seeking therapy as a viable treatment option.

H5: The final two hypotheses explored theoretical propositions of media theories to investigate audience involvement and persuasion. It was estimated that those with increased psychological distress would experience greater identification (transportation) with the portrayal.

H6: In keeping with the theoretical propositions of audience involvement and narrative induction, it was predicted that those with greater psychological distress would also have greater levels of narrative engagement with the portrayal. 28

METHOD

Participants

There were 208 participants in the study. All participants were undergraduates at a large Midwestern university enrolled in an introductory psychology course. The majority of participants were female (n =126) and identified themselves as Caucasian (n

=177) on a demographic questionnaire. Most participants were 19 years old with a range of ages from 18 to 28 years (M =19.5). The majority were freshman at the university (n =

121) and the most common educational major in the study was Journalism (n = 36).

Approximately 27% of the participants had an OQ-45 score greater than 63 (n = 57), indicating that they could be classified as “distressed” using the norms for college student populations (Lambert, Whipple, Hawkins, Vermeersch, Nielsen, & Smart, 2003).

Approximately 17% of the participants endorsed previous psychotherapy experience (n =

36). A power analysis indicated that at least 40 subjects would be needed in each grouping of participants to obtain an optimal alpha (α = .05) and desirable levels of power (1-β = .80). This was achieved, and the distribution of participants by grouping was 61 and 62 for the treatment conditions and 82 for the control group.

Materials

Participants were shown clips of a therapist talking directly to an individual client over several sessions of individual therapy. These clips were taken directly from the first season of the HBO television drama In Treatment (Garcia, 2008), which chronicles therapist Dr. Paul Weston (Gabriel Byrne) and clients whom he sees each week. Each 30- minute episode depicts one session of psychotherapy. All clips in the study were 29 obtained according to U.S. fair use guidelines, allowing for limited use of copyrighted materials in non-profit research situations.

In Treatment (Garcia, 2008) has garnered praise from both critics and professionals, which made it a reasonable selection for this study. Many have considered it the most realistic fictional portrayal of therapy to date, describing it as the zenith of psychotherapy portrayals, providing viewers with a glimpse of what truly occurs during therapy (Rabinowitz, 2008; Schwartz, 2008; Trebay, 2008). Therapy professionals have weighed in on how In Treatment compares to its real-world counterpart. Glen Gabbard

(2008), noted author and expert on media portrayals of therapy, described the content of the show as unusual yet plausible, with a therapist who deftly manages resistance while fostering the therapeutic alliance. He described the show as “the most convincing psychotherapy ever seen on television,” presenting therapists in a realistic manner

(neither idealizing nor vilifying) which allows viewers the chance to, “eavesdrop on private therapy sessions...and hear what a therapist hears (p.1).”

Similar to the Robison and Ogles (2009) study, clips from the show were divided into either positive or negative conditions. Formal definitions of media therapy proposed by Schultz (2006) of “good therapy” (working toward the client’s well-being, observing ethical boundaries, and the client appearing healthier or happier) and “bad therapy”

(where the client appears harmed, boundaries are broken, or the outcome appears detrimental to the well-being of the client), were employed to ensure that an operationalized approach was used with the portrayals. 30

To prepare the stimuli for the study, it was necessary to edit the length of the portrayals to a time that would be sufficient for content while still allowing for participants to have enough time for completing the study measures. The show was first edited into one longer compilation (approximately 4.5 hours) containing every encounter between the therapist and individual client. One coherent storyline was subsequently chosen that would maximize the positive or negative nature of the portrayal. These were then edited down to approximately equal lengths of time for each condition. The final running time for the positive portrayal was 44 minutes, the negative portrayal was 46 minutes, and the control presentation was 39 minutes.

The story for the negative portrayal of therapy used in the study followed a patient’s attraction to her therapist. This began with her disclosing sexual feelings and the therapist’s initial enforcement of therapeutic boundaries. It then showed the patient arguing against the purpose of these boundaries and the pointless nature of therapy.

Eventually their therapeutic relationship is dissolved and the patient terminates her treatment. The portrayal ended with the therapist arriving at the patient’s home, declaring his desire for a relationship with her. He then goes with her into the bedroom, creating an ambiguous ending regarding any sexual behavior.

For the positive portrayal’s story followed a teenager who is mandated to therapy by her insurance company following a bicycle accident. This is soon revealed to be a suicide attempt, caused by her underlying unhappiness related to her father’s abandonment. The first few sessions showed the therapist fostering rapport and managing her reluctance to open up. In the culmination of the portrayal, the therapist 31 supported his client as she brought her father into the session in order to assertively express her feelings of abandonment and reveal her attempted suicide. Following this cathartic session, there was a mutual termination of therapy. The ending showed an emotionally stronger client hugging her therapist, clearly grateful for the work they had done and the bond they had shared, and feeling ready to move forward in her life.

In order to create the greatest level of experimental continuity, it was essential that the control presentation incorporate as many elements as possible from the other two clips, but without any display of therapy, patient/therapist interaction, or the therapist’s profession being disclosed to the audience. To accomplish this, a separate plotline was used, focusing on the interaction between the therapist and his children. This storyline showed a father connecting with his children and discussing relationship concerns between him and their mother. He first speaks to his oldest son who has returned home during a break from college, dispelling fatherly advice about relationships while also disclosing details of his own life. He then talks with his teenage daughter, discussing her dating a new boyfriend. The presentation ended with the father and daughter looking out the window contemplatively as the camera pans out.

Measures

Demographics Questionnaire

Participants were given a questionnaire that gathered information about their age, gender, academic year, race/ethnicity, and relationship status. In addition to these standard demographic questions, participants were asked about their previous exposure to 32 psychotherapy, as this was relevant to their prior beliefs about treatment. They were also asked about their level of media exposure and television viewing habits.

Expectations About Counseling – Brief Form

The Expectations About Counseling – Brief Form (EAC-B) (Tinsley, Workman,

& Kass, 1980) is a 66-item, 7 point likert-type scale, that measures treatment expectations on five scales including client attitudes and behaviors, client characteristics, counselor attitudes and behaviors, counselor characteristics, and counseling process. Scores are summed together to calculate a single score. Subsequent factor analyses (Hatchett, 2006) have clarified three distinct constructs measured by the EACB including: facilitative conditions, counselor expertise, and client involvement. The EAC-B correlates well with its full scale counterpart, with a median reliability of .77 in university populations, and a test-retest reliability of .60 (Tinsley, de St. Aubin, & Brown, 1982).

While the EAC-B may be the best measure of treatment expectations currently available to researchers, there have been concerns about its construct validity in distinguishing between expectations of counseling and preferences for certain types of counseling (Ducko, Beal & George, 1979; Tinsley, de St. Aubin, & Brown, 1982).

However, studies have shown that the Brief Form is free from major attacks on validity and does indeed measure expectations as opposed to preferences (Tinsley, Bowman, &

Ray, 1988). In the current study participants were asked to complete the EAC-B as if they were beginning treatment with a psychotherapist for the first time. Because it is likely that expectancies could be shaped by prior treatment experience (Von Sydow & 33

Reimer, 1998), previous treatment was assessed by the demographics questionnaire and compared to scores on the EAC-B.

Thoughts about Psychotherapy Survey

The Thoughts about Psychotherapy Survey (TAPS) (Kushner & Sher, 1989) measures participants expectations about seeing a psychotherapist and receiving treatment for psychological distress. The TAPS is a 19-item likert-type scale ranging from 1 (I would not be concerned about this) to 5 (this would be a concern for me). There are 3 subscales measured by the TAPS: therapist responsiveness (precise client fears about therapist’s responses), image concerns (negative judgments for seeking services), and coercion concerns (fears related to being pushed to do things they would not want to). Internal consistency for each subscale is good: therapist responsiveness (.92), image concerns (.87) and for coercion concerns (.88). The TAPS has been shown to measure beliefs and distress about psychotherapy, with those who have more fears (higher scores) being less likely to seek services (Deanne & Todd, 1996). In the current study participants were asked to complete the TAPS as if they were seeking treatment for a concern.

Attitudes Toward Seeking Professional Psychological Help Scale

The Attitudes Toward Seeking Professional Help Scale: Short Form (ATSPPHS)

(Fisher & Farnia, 1995) is a 10-item scale developed for use in a variety of clinical settings with potential responses ranging from 1 (disagree) to 4 (agree). It measures participants’ agreement with different aspects of mental health professionals and treatment. A higher score on the scale reflects more positive attitudes toward seeking 34 psychological help. It has been found to have good internal consistency reliability (.82-

.84) among different populations (Vogel et al., 2005).

Stigma Scale for Receiving Psychological Help

The Stigma Scale for Receiving Psychological Help (SSRPH) (Komiya Good, &

Sherrod 2000) is a 5-item questionnaire with responses ranging from 0 (strongly disagree) to 3 (strongly agree). The total summed score indicates a greater perception of social stigma associated with counseling. The internal consistency of the measure has been found to be acceptable, ranging from (.73-.78) and is negatively correlated with the

ATSPPHS (r = -.40, p <. 001) (Komiya et al., 2000).

Outcome Questionnaire-45

The Outcome Questionnarie-45(OQ-45) (Lambert, Lunnen, Umphres, Hansen, &

Burlingame, 1994) is a brief yet informative 45-item self-report measure of psychological distress. Responses occur on a 5-point scale that ranges from 0 (never) to 4 (almost always). It asks respondents to rate several items on three subscales including: symptom distress, interpersonal relationships, and social role functioning. A summated total score can range from 0 to 180. Higher scores are indicative of greater levels of distress in social situations, relationships, and personal functioning.

The OQ-45 is both practical and psychometrically sound (Ogles, Lambert, &

Fields, 2002). It has a test-retest reliability ranging from .66 to .86 and high internal consistency (.93) (Lambert, 1999; Lambert, Whipple, Hawkins, Vermeersch, Nielsen, &

Smart, 2003). The OQ-45 is concurrently valid with similar psychological measures including the SCL-90, BDI, Zung Depression Scale, and STAI (Ogles, Lambert, & 35

Masters, 1996) and can be easily understood and applied in non-clinical populations. For college student populations the average total score for the OQ-45 is 42.33 with a standard deviation of 16.60 (Lambert et al. 1994). An OQ-45 score of 63 has been consistently indicative of likely clinical distress (Lambert et al, 2003). In the current study the OQ-45 was used to measure the psychological distress of the participants.

Transportation Scale

The Transportation Scale (TS) (Green & Brock, 2000) is a 15-item scale that uses a likert-type range from 1 (strongly agree) to 7 (strongly disagree). It assesses the viewer’s level of absorption into the narrative of the story on several concepts, including attention, emotional involvement, and awareness of surroundings. It has been found to have good reliability (ranging from .76-.87) (Braverman, 2008; Green, 2004; Green &

Brock, 2000). It has been established as short, easily answered scale that can be adapted to any narrative. For the purposes of this study only 11 of the 15 items were used, as items 12-15 are only used to ask specific narrative related questions.

Narrative Engagement Scale

The Narrative Engagement Scale (NES) (Busselle & Bilandzic, 2009) is a 12-item likert-type scale that measures the level of viewer induction into the media’s dramatic storyline on 4 different factors: narrative understanding, attentional focus, narrative presence, and emotional engagement. It has been found to have good reliability (.80) with individual factors ranging from .70 to .79 (Busselle & Bilandzic, 2009; 2010). 36

Self-Report Survey

A 6-item scale was developed as part of the post-measure packet. Because of the disagreement between expert and lay ratings (Robison & Ogles, 2010) it was necessary to assess participants overall impressions of the psychotherapy portrayal. Using a 6-item likert-type scale, participants were asked about their perception of the portrayal being either positive or negative representations of both psychotherapy and the psychotherapist.

It also assessed the perceived realism of the portrayal, their likelihood of seeking therapy, and their likelihood of recommending therapeutic treatment to others.

Procedure

Students enrolled themselves as available for participation in psychological research as part of their psychology course requirement. An online prescreen was completed at the beginning of the academic quarter that contained several measures for multiple studies, including the pretest measures for this study. Completion of this prescreen was required to be eligible for participation in the latter part of the study.

Students then enlisted in the study via an online sign up system. Participants were compensated two course extra-credit hours, which was determined by the 2-hour length of time required for their participation.

After signing up for the study online, students arrived for participation at the designated university classroom capable of accommodating several participants (15-20).

Upon their arrival, participants signed in and provided their name and student identification number to ensure they received course credit. This same sign-in sheet was later used to link their post-measures to those from the online prescreen. Participants 37 were randomly assigned to seating placements at least one seat apart from others. This was done to reduce the potential influence from other participants and to allow for privacy while completing the study measures.

A three-condition design was used (two treatments and one control) to allow for between group comparisons. The type of condition for each study time slot was randomly chosen by the experimenter by selecting one of 3 external media drives, identical in appearance, each containing a different portrayal stimulus. The instructions for the study were then read aloud from a pre-prepared sheet to ensure that each condition received uniform instructions. A short demographics questionnaire was then given to participants, including the OQ-45 (Lambert, 1999). Completion time for this first questionnaire was approximately 5-10 minutes.

After the initial materials were completed the lights were dimmed and the prepared clips from In Treatment (Garcia, 2008) were shown on a large screen through a projector. During the presentation, participants completed a short 4-question survey that served as a manipulation check to verify that they attended to the material and stayed awake during the presentation. This survey assessed simple face value elements that were explicitly stated during the portrayal, such as, “The male character in this clip is named…,” with four possible choices provided. Students who did not answer all 4 questions correctly were not included in the analysis. For all who participated, only 9 failed the manipulation check, 3 of whom fell asleep and 6 whose primary language was not English; none were docked compensation for their participation. 38

Immediately after the conclusion of the media portrayal, the projector was turned off and the lights were restored to their normal luminescence. The post-measures were then distributed to the participants and they were instructed to place the first and last initial of their names on the packet in a designated area. The majority of participants completed the post-measures, typically within 35-40 minutes. Once they were finished with the post-packet, participants brought all measures to the front of the room and turned them in to the researcher before leaving.

Completed measures were placed in a large box that was used to transport study materials and then returned to the researcher’s office. The sign in sheets, which contained identifying information, were locked in a file drawer within a locked office according to the university’s Institutional Review Board guidelines. The measures were placed in a separate drawer within the same locked office. The student identification number and name from the sign-in was used to match their pre and post measures that were then combined into one participant file that was later used for analyses on a statistical computer package 39

RESULTS

Tests of group equivalence showed that there were no significant differences between study conditions in terms of gender, age, race, school year, or major. No differences were found between the groups in utilization of previous therapy, in total OQ-

45 scores, or in the amount of participants classified as clinically distressed based on OQ-

45 cutoff scores, F(2,207) = .251, p = .778. There were also no significant differences between the study conditions on the pre-test measures, Wilks’ Lambda = 0.990, F(2,199)

= 0.989, p = .374. This indicated that participant’s previous expectations and attitudes about therapy were similar across the conditions and that homogenous groups could be assumed prior to exposure to the fictional psychotherapy portrayals. Means and standard deviations of post-measure scores are presented in Table 1.

A One-way Analysis of Variance (ANOVA) was performed on each of the self- survey items to assess for differences between the study conditions. Because more participants were in the control condition than the two treatment conditions due to their random assignment, Welch corrections were conducted to ensure equal variances could be assumed. The results showed that there were significant differences across study conditions on participant’s perception of the positive or negative nature of both the psychotherapy portrayal, F(2, 190) = 7.807, p = .001) and the portrayal of the therapist,

F(2, 190) = 16.372, p < .001. While participant’s perceived realism of the therapist was significantly different between groups, F(2,190) = 6.674, p = .002, their rating of the portrayed therapy’s realism was not significant, F(2,190) = 2.468, p = .08. This suggested that each variable related to participant’s perceptions of the portrayals significantly 40 differed across the groups except for the perceived realism of the portrayed therapy.

Group differences were also found for interest in seeking psychotherapy, F(2,190) =

15.817, p < .001, and recommending therapy services to others, F(2,190) = 12.197, p <

.001.

Paired comparisons of means from the self-survey were conducted, revealing that the clips were interpreted in the predicted positive or negative directions. Group means tended to be close to neutral (4) on the 7-point scale, except for those of the positive portrayal condition, which tended significantly differed from those in the other conditions

(see Table 2). Those in the positive portrayal condition viewed both the therapy and therapist as more positive (p < .01) and realistic (p < .05), and also had greater interest in seeking therapy (p < .001) and recommending it to others (p < .001) when compared to the control condition. Those in the negative condition rated the portrayal as more negative, less realistic, and had less interest in seeking or recommending therapy when compared to the control group, but this was only significant for the participant’s interest in seeking therapy (p < .01). All comparisons between the two portrayal groups were significant (p <.01) except for perceived realism of therapy.

Main Hypotheses

Portrayals impact on expectations and seeking attitudes

To test the overall effects of the media portrayals on expectations of psychotherapy (H1) and attitudes toward seeking treatment (H2), two separate

Multivariate Analyses of Covariance (MANCOVA) were performed. Participant’s responses on pre-study measures and previous therapy experience were used as 41 covariates to account for any expectations and attitudes that existed prior to their participation in the study. This ensured that any observed effects between groups could likely be attributed to the exposure to the media portrayals.

For measures of the portrayals overall impact on participant’s expectations about treatment (H1), the multivariate omnibus test showed there were no significant differences between study conditions, Wilks’ Lambda = .0964, F(4,380) = 1.778, p =

.133, when accounting for pre-study expectations. Participant’s pretreatment expectations were significant covariates, (p < .001) for both the EACB and the TAPS, but previous therapy was not significant (p =.652).

The overall multivariate analysis on seeking attitudes (H2) examined the impact of television psychotherapy portrayals on viewer’s attitudes toward seeking therapy, intentions to seek treatment, and the perceived stigma associated with obtaining psychological help. The results showed there was a significant difference between the groups, Wilks’ Lambda = .942, F(4,390) = 2.963, p = .02, when accounting for pre- existing attitudes toward treatment. Participants’ responses on pretest measures, (p <

.001) for ATSPPH, ISCI, and SSRPH), and previous therapy experience, (p = .006), were both significant covariates in the analysis.

Because the findings of the omnibus multivariate test were significant, individual univariate analyses were evaluated, revealing that the ATSPPH accounted for the majority of the variance, F(2,197) = 3.324, p = .038. The ISCI was not significant

F(2,197) = 1.069, p = .345, nor was the SSRPH, F(2,197) = 3.324, p = .855. This indicated that the portrayals influenced participant’s beliefs about seeking therapy more 42 than their intentions to do so or their level of perceived stigma associated with obtaining psychotherapy treatment.

Comparisons of positive & negative conditions

Because mean relationships were hypothesized prior to the study, a prioi pairwise comparisons were used to compare each treatment condition to the other and the control group. These analyses were performed to measure the direction and strength of group differences on expectations (H3) and seeking attitudes (H4). Along with general expectations, the three factor variables (facilitative conditions, client involvement, and counselor expertise) of the EAC-B were also examined.

The pairwise comparisons predicting directions of the portrayals influence on expectations (H3) showed there was a significant difference between those in the positive portrayal condition and the control on the EAC-B, t(205) = 2.109, p = .036. However, the mean differences were not in the predicted direction, with those in the positive condition having lower mean scores (more negative expectations of therapy) than those in the control condition. Paired mean comparisons on EAC-B factors revealed a significant difference between means of the positive (M =3.17) and negative (M =3.53) portrayal conditions for Counselor Expertise, t(190) = 2.247, p = .026, but again the direction was not as predicted. This implied that those in the portrayal group had more negative expectations of the portrayed therapist’s skills. No comparisons for Facilitative

Conditions and Client Involvement factors were significant.

Pairwise comparisons for the TAPS found significant differences between the positive and negative conditions, t(206) = 1.967, p = .05, but only approached 43 significance when comparing the positive portrayal condition to the control group, t(206)

= 1.893, p = .06. The distribution of the means were in the expected directions, with those in the positive portrayal condition having lower scores (M = 3.12), thus fewer concerns about what might happen in psychological treatment, than controls (M = 3.36).

Comparisons between the negative portrayal condition (M = 3.34) and the control group were not significant, t(205) = .975, p = .331.

Means of seeking attitudes across study conditions (H4) were all distributed as predicted. Participants in the negative condition had more negative beliefs and intentions toward seeking treatment than those in the control group, while those in the positive portrayal condition had fewer concerns. However, the pairwise comparisons showed only limited effects between treatment conditions for ATSPPH, with mean differences between the positive (M = 1.24) and negative (M = 1.40) conditions only being marginally significant, t(206) = 1.86, p = .06. Comparing the positive portrayal group to the control condition (M = 1.32) also only approached significance, t(206) = 1.691, p =

.09. Differences between the negative and controls were not significant, t(206) = .862, p

= .309. This showed that while the participant’s perception of the portrayals was directed as expected, the differences between conditions was greater for reducing concerns about seeking psychological treatment for those in the positive condition while the negative and control conditions did not significantly differ from each other.

Narrative induction predicted by psychological distress

Two separate regression analyses were conducted to investigate the possible influencing factors proposed by media theories of persuasion such as E-ELM (Slater & 44

Rouner, 2002; Moyer-Guse, 2008). These explored whether or not variables of persuasion related to personal induction into the narrative, transportation (H5) and narrative engagement (H6), were predicted by psychological distress.

Contrary to predictions, the results of the regression analysis on transportation into the story (H5) showed that distress was not predictive, β = .12, F(1,205) = 2.739, p =

.09. While the regression analysis on narrative engagement (NES) and psychological distress (H6) showed that distress did significantly account for some of the variance, this was not in the direction that was predicted by the hypothesis, β = .17, F(1,206) = 6.43, p

= .01. This indicated that increased psychological distress was predictive of less personal engagement with the dramatic narrative.

Post-Hoc Examinations

The OQ-45 total score was used as a continuous variable in the previous analysis.

To corroborate these results, independent samples t-tests were conducted for each study measure, using distress as a dichotomous variable. Group differences were then examined between those who are classified as distressed (N = 57) or not distressed, (N =

151) as determined by a score higher than 63 on the OQ-45. Welch corrections were due to the unequal group sizes. While there were no significant findings for expectations of therapy, the results did show there was significant difference between those who were clinically distressed and those who were not clinically distressed in their intentions to seek counseling, t(206) = 3.2, p = .001. Those who were above the cut-off score for distress had slightly higher intentions to seek therapy (M = 3.27), as measured by the

ISCI, than those where were not distressed (M = 2.78). Retesting the study hypotheses to 45 explore any possible changes that might result from using differentiations between distressed or non-distressed groups reconfirmed all previous findings.

Because “perceived realism” of therapy was found to be the only non-significant difference between the different study conditions on the post-exposure self-report survey, it was sensible to investigate how perceived realism related to other variables and to test for any impact that it might have had on expectations, attitudes about psychotherapy, or personal identification with the portrayal. Correlative analyses showed that perceived realism of therapy was positively correlated with participant’s evaluation of the portrayals. This was the case for both the portrayal of therapy (r = .55, p < .001) and the portrayal of the therapist (r = .66, p < .001). Realism of the therapy and therapist were also highly correlated with each other (r = .71; p < .001).

To explore any potential impact of perceived realism of therapy on other study variables, the multivariate analyses of covariance on expectations and seeking attitudes were again conducted, adding perceived realism as a covariate. The results showed that perceived realism was not a significant covariate for attitudes toward seeking treatment (p

= .545), but was a significant covariate for expectations (p = .041). Perceived realism did reduce the within-group error variance and increased the significance of the omnibus test for expectations of therapy, Wilks’ Lambda = .957, F(4,378) = 2.068, p = .084. However, this did not change the interpretation of the results and still showed no significant differences between conditions.

Because of the lack of significance for the hypotheses on narrative induction, further exploration and correlation analyses were also conducted to investigate the nature 46 of these findings. As would be expected from theories of persuasion, narrative engagement and transportation were significantly correlated with each other (r = .74, p <

.001). Both variables were also related to the perceived realism of the therapy (r = -.18,

TS; r = -.22 NES), perceived realism of the therapist (r = -.33, TS; r = -.31, NES), and the perception of the positive or negative nature of the portrayed therapy (r = -.27, TS; r

= -.26, NES) and the portrayed therapist (r = -.26, TS; r = -.31, NES). This indicated that as participant’s perception of the positive nature and realism of the portrayal increased, so did their levels of narrative engagement and transportation along with, theoretically, how persuaded they were by the portrayal.

DISCUSSION

There were three major areas of inquiry explored by the hypotheses of this study

(Table 4). The first examined the impact of fictional media portrayals of psychotherapy on expectations about treatment, which included how the type of portrayal viewed influenced participants’ beliefs about therapy in either positive or negative ways. The second aim of the study investigated how attitudes about seeking psychotherapy were influenced by the portrayals in both positive and negative directions. The third area of investigation sought to uncover whether psychological distress was predictive of viewers’ level of personal involvement with the narrative of the psychotherapy media portrayals.

The results of the study showed that general expectations of treatment were not influenced by television portrayals of psychotherapy. However, specific beliefs about the therapist’s expertise and concerns about what might occur during therapy significantly differed between the portrayal conditions. The results showed that those who viewed positively rated portrayals of psychotherapy had more negative expectations of treatment than those in the control group. This was contrary to the prediction that viewing positive portrayals of therapy would result in more positive expectations and vice versa. These findings were consistent with previous studies that attributed this inverse pattern to a possible genre effect (Robison & Ogles, 2009). The greater methodological control present in the current study, such as using a consistent genre of media across conditions, corroborated the consistency of this unexpected result. Because of this, potential explanations for both the non-significant findings and the inverse relationship between positive depictions of therapy and expectations should be considered. 48

Many previous investigations showing a significant relationship between media portrayals of psychotherapy and beliefs about treatment have used self-created measures to assess specific therapist behaviors rather than more exhaustive measures (see Schill,

Harsh, & Riter, 1990). The limited findings for the EAC-B could be a product of it being a more comprehensive measure for assessing multiple beliefs about treatment. It is possible that the elements of therapy portrayed in this study were too limited to correspond with the wide range of expectations assessed by the EAC-B, making it too broad of a measure to capture the impact of only one media exposure. However, the portrayed therapy may still have depicted specific behaviors that might occur during therapy. This may explain why the TAPS, a more concise measure of specific concerns, was significant across conditions in the predicted directions while the EAC-B was not.

The contradictory relationship between expectations and the nature of the therapy portrayal could also be explained by previous research on expectations of treatment.

Tinsley, Bowman, & Barich (1993) proposed that clients potentially begin therapy with unrealistic expectations that could be detrimental to treatment. For example, some clients erroneously believed that the therapist would provide direction on how they should behave. Studies have previously established that the counselor expertise factor of the

EAC-B, which accounts for beliefs about how directive the therapist might be, is inversely related to ratings of the therapeutic alliance (Tokar, Hardin, Adams, & Brandel,

1996). Whitaker, Phillips, and Tokar (2004) found that clients who watched a video that oriented them to counseling had lower scores on the counselor expertise factor of the

EAC-B than those in a control condition, which indicated that the video decreased 49 expectations of the therapist acting in prototypically expert ways. This finding is consistent with the results of the current study, where the counselor expertise factor of the EAC-B was significantly lower for those in the positive portrayal condition than either the control group or the negative portrayal condition. As was predicted, the media depiction of therapy could have simply provided both a positive and realistic depiction of therapy that corrected prior unrealistic beliefs about therapeutic treatment.

Unlike expectations, viewers’ attitudes about seeking therapeutic treatment were significantly influenced by media portrayals. The results showed that those who viewed the negative portrayal had greater concerns about seeking psychotherapy, confirming what many professionals have previously speculated (Gabbard & Gabbard, 2001; Jorm,

2000). However, the results of this study also showed that positive media portrayals of treatment promoted seeking treatment, with the positive portrayal having a more substantial impact on decreasing concerns about seeking therapy than the negative portrayal’s detrimental effects. This is contrary to typical perceptions of therapy as portrayed by popular media, which is thought to be more deleterious than beneficial.

Additionally, the effect on seeking behavior was not related to changes in perceived stigma. In fact, viewing the portrayals had no effect on perceived stigma, contrary to findings from previous studies that proposed a relationship between exposure to therapy portrayals and increased stigma (Vogel, Gentile, & Kaplan, 2008).

The final aim of the current study attempted to shed further light on how media portrayals of therapy persuade, particularly for those whom might be potential consumers of therapy. Earlier research has shown that personal similarity and relevance can 50 influence induction into the narrative of media (Moyer-Guse & Nabi, 2010; Slater,

Rouner, & Long, 2006). Given these findings, it made sense to predict that those with greater psychological distress might find portrayals of psychological treatment to be more personally relevant to their own experiences. Contrary to these predictions, the results did not find that psychological distress predicted personal engagement with therapy portrayals in a college student population. In fact, those with greater levels of psychological distress actually became less engaged with the portrayed narrative.

The influence of distress on involvement with the narrative might further be reflective of the impact of distress on attention and detachment. Individuals with greater anxiety are thought to engage in adaptive avoidant coping, especially when exposure to a stressor is unavoidable (Compas, et al 2001). If the portrayal of therapy was truly reminiscent of a viewer’s own experience, it may be a possible trigger for greater distress, and disengaging could be a strategy of avoidance. This would be consistent with the finding that those with greater distress were less engaged with the portrayal of treatment.

The internal distraction of those with greater distress has also been shown to influence the ability to attend to external stimuli (Yiend, 2010). Those entering the study with increased psychological distress might have had greater internal distraction and were thus unable to become as involved in the narrative.

The lack of evidence for distress predicting narrative engagement may also be indicative of variables other than distress that might be more predictive of personal involvement with therapy portrayals. One such factor could be program enjoyment, which has been shown to predict personal involvement with characters in fictional media 51

(Quintero Johnson, Harrison, & Quick, 2013). Another recent study has shown that manipulating personal identification by switching a viewer’s perspective between two different characters from fictional media influenced both narrative engagement and the level of induction (de Graaf, Hoeken, Sanders, & Beentjes, 2012).

The results of this study established that fictional televised portrayals of psychotherapy have the potential to influence viewers’ concerns and attitudes about seeking psychotherapy treatment. This provides some support for the attention that is given to therapy portrayals by the profession (APA, 1986; Gabbard & Gabbard, 1999;

Wedding & Niemic, 2003). Although media is likely not the sole factor that influences beliefs about psychotherapy treatment, this study showed that attitudes and expectations were impacted in both positive and negative ways, even from merely one media viewing.

Repeated exposure to these depictions would most likely compound this effect (Hasan,

Begue, Scharkow, & Bushman, 2013; Morgan & Shanahan, 2010). This study further showed that individuals who are distressed (and potential consumers of therapy) were not influenced by the media portrayals to a greater degree than non-distressed viewers.

One final point warranting consideration, especially when examining the impact of media, is the significance of non-significant findings. It has long been assumed that television directly influences individual beliefs and public opinion at large (Gerbner,

Gross, Morgan, Signorelli, & Shanahan, 2002). More recently the idea of the direct effects of television influence has been criticized by media researchers, who have focused more on indirect factors such as the level of attention and personal involvement related to media (Buijzen, van der Molen, & Sondij, 2007; Kirsch, 2011). The overall results of this 52 study showed the impact of therapy portrayals to be either non-significant or small at best, so the concerns about therapy portrayals by those in the profession could be exaggerated. It is a distinct possibility that viewers of television maintain an element of willing disbelief, something previously thought to explain mismatched reactions to real- world versus fictional media (Meyer, 2005). Even a very realistic portrayal of fictional therapy could still be seen as mere fiction by the majority of those who view it and thus have only a limited impact on their real-world beliefs.

Limitations & Directions for Future Research

Many efforts were made in the current study to maximize internal validity by using a portrayal of therapy that was realistic and rife with therapy content. As is the case in experimental research designs, the increased internal control also limits the external validity of the results. In this case, the use of the television show In Treatment, a dramatic and uniquely therapy-focused depiction of treatment, may not be reflective of the majority of therapy portrayals encountered by viewers. The show also presents a specific style of therapy that is unrepresentative of all of the various approaches to psychological treatment. Because the study operationalized a positive portrayal of psychotherapy, it is possible that participants had their own various interpretations of what constitutes

“positive” therapy that were not fully assessed. Finally, because participants did not watch the portrayal by their own choosing, variables related to self-selection of media were not accounted for in this study.

Other confines were also inherent in the methodology of this study, limiting its generalizability. These included the similarity between the control condition and the 53 negative portrayal condition as well as the viewer’s one-time (rather than longitudinal) exposure to portrayals. Using college students as participants, who may hold more accepting attitudes toward therapy and consume several forms of media other than television, may limit the potential comparisons to the general population. Future research could use several diverse forms of media and specific types of therapy portrayals simultaneously in a longitudinal design that tracks viewer’s beliefs over time. Later studies could also assess for specific types of behaviors that occur in therapy with measures that assess these behaviors in valid ways.

The present study also did not distinguish between participants’ identification with either the client or the therapist character. This could have possibly affected the relationship between a viewer’s distress and their level of narrative induction. Further exploration of personal factors related to the impact of these portrayals, such as character identification, could provide greater understanding of whom these portrayals of treatment are most likely to impact.

Finally, future research should address how portrayals of therapy in popular media influence and inform clinical treatment. It is possible that certain client characteristics, such as misaligned expectations coming from media, have the potential to impact the therapeutic relationship. The findings of this study regarding expectations and attitudes lend some support to this notion. The use of multimedia interventions in other settings has been shown to reduce fears and concerns related to seeking counseling

(Fende & Anderson, 2007). However, the use of media in altering expectations of treatment has shown inconsistent results in prior research (Johansen, Lumley, & Cano, 54

2011; Whitaker, Phillips, & Tokar, 2004). Despite these mixed results, expectations of therapy are both crucial to the success of therapy and alterable, which emphasizes the importance of clinicians addressing client expectations early in treatment (Holt &

Heimburg, 1990). While it is unlikely that this would account for all previous media exposure and pretreatment beliefs, it is important that clinicians implicitly or directly attend to the many expectations about therapy that clients may have when entering treatment. Discussing these expectations during the early stages of therapy, while also understanding how media may influence these beliefs, could help align therapists and clients on the goals of treatment and improve therapeutic rapport. 55

CONCLUSION

This study provided understanding not only about the impact of psychotherapy portrayals in media, but also the mechanisms that influence and contribute to their effects. The results of this investigation clearly establish that media portrayals of psychotherapy can influence viewer’s attitudes and beliefs about seeking therapeutic treatment, even after only one exposure when holding previous beliefs constant. The results of this study provide empirical support for an area previously marred with speculation in the absence of sound evidence. It lays the empirical groundwork for future exploration and refutation of such claims.

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TABLES

Table 1

Post Exposure Means (SD) for Dependent Variables by Condition

Measures Negative Portrayal Control Condition Positive Portrayal EAC-B 4.84 (.85) 4.96 (.53) 4.69 (.85)

TAPS 3.34 (.68) 3.36 (.64) 3.12 (.90)

ATSPPH 1.40 (.49) 1.32 (.58) 1.24 (.43)

ISCI 2.98 (1.1) 2.96 (.98) 2.79 (.96)

SSRPH 1.41 (.57) 1.38 (.50) 1.40 (.46)

TS 4.27 (.84) 4.16 (1.03) 3.86 (.93)

NES 3.86 (.93) 3.87 (1.09) 3.31 (1.03)

Table Measures: Expectations of Counseling – Brief Form (EAC-B), Thoughts About Psychotherapy Survey (TAPS), Attitudes Toward Seeking Professional Psychological Help Survey (ATSPPH), Intentions to Seek Counseling Inventory (ISCI), Stigma Scale for Receiving Psychological Help (SSRPH), Transportation Scale (TS), Narrative Engagement Scale (NES).

Table 2

Contrasts Between Means (SD)

Self-Survey Negative Control Positive Items Portrayal Group Portrayal Therapy (+/-) 4.23 (1.45) 4.52 (0.96) 5.21 (1.10)**

Therapy Realism 4.25 (1.31) 4.26 (1.46) 4.82 (1.41)**

Therapist (+/-) 4.11 (1.38) 4.40 (1.08) 5.49 (1.07)*

Therapist Realism 4.11 (1.53) 4.39 (1.24) 5.08 (1.20)***

Interest in Seeking 3.87 (1.64)* 4.28 (0.99) 5.33 (1.01)***

Recommending 3.75 (1.16) 3.66 (1.42) 4.85 (1.16)***

Note. *p <.05, **p <.01, ***p <.001

Table 3

Correlations Between Constructs

Measures EAC-B TAPS ATSPPH ISCI SSRPH TS NES EAC-B

TAPS .346***

ATSPPH -.200** .002

ISCI .217** .188** -.516***

SSRPH -.125 .185** .342*** -.107

TS -.058 -.020 -.008 -.035 -.035

NES -.124 .067 -.015 .020 .031 .738***

Note. *p < .05, **p < .01, ***p < .001

APPENDIX A: EXPECTATIONS ABOUT COUNSELING – BRIEF FORM

Imagine that you are going to see a therapist for your first interview. We would like to know just what you think therapy will be like. On the following pages are statements about therapy. In each instance you are to indicate what you expect therapy to be like. Indicate your response

___1. I EXPECT TO Take psychological tests. 1 2 3 4 5 6 7 Not Slightly Somewhat Fairly Quite Very Definitely True True True True True True True ___2. I EXPECT TO Like the counselor. 1 2 3 4 5 6 7 Not Slightly Somewhat Fairly Quite Very Definitely True True True True True True True ___3. I EXPECT TO See a counselor in training. 1 2 3 4 5 6 7 Not Slightly Somewhat Fairly Quite Very Definitely True True True True True True True ___4. I EXPECT TO Gain some experience in new ways of solving problems within the counseling process. 1 2 3 4 5 6 7 Not Slightly Somewhat Fairly Quite Very Definitely True True True True True True True ___5. I EXPECT TO Openly express my emotions regarding myself and my problems. 1 2 3 4 5 6 7 Not Slightly Somewhat Fairly Quite Very Definitely True True True True True True True ___6. I EXPECT TO Understand the purpose of what happens in the interview. 1 2 3 4 5 6 7 Not Slightly Somewhat Fairly Quite Very Definitely True True True True True True True ___7. I EXPECT TO Do assignments outside the counseling interviews. 1 2 3 4 5 6 7 Not Slightly Somewhat Fairly Quite Very Definitely True True True True True True True ___8. I EXPECT TO Take responsibility for making my own decisions. 1 2 3 4 5 6 7 Not Slightly Somewhat Fairly Quite Very Definitely True True True True True True True ___9. I EXPECT TO Talk about my present concerns. 1 2 3 4 5 6 7 Not Slightly Somewhat Fairly Quite Very Definitely True True True True True True True ___10. I EXPECT TO Get practice in relating openly and honestly to another person within the counseling relationship. 1 2 3 4 5 6 7 Not Slightly Somewhat Fairly Quite Very Definitely True True True True True True True ___11. I EXPECT TO Enjoy my interviews with the counselor. 1 2 3 4 5 6 7 Not Slightly Somewhat Fairly Quite Very Definitely True True True True True True True 80

___12. I EXPECT TO Practice some of the things I need to learn in the counseling relationship. 1 2 3 4 5 6 7 Not Slightly Somewhat Fairly Quite Very Definitely True True True True True True True ___13. I EXPECT TO Get a better understanding of myself and others. 1 2 3 4 5 6 7 Not Slightly Somewhat Fairly Quite Very Definitely True True True True True True True ___14. I EXPECT TO Stay in counseling for at least a few weeks, even if at first I am not sure it will help. 1 2 3 4 5 6 7 Not Slightly Somewhat Fairly Quite Very Definitely True True True True True True True ___15. I EXPECT TO See the counselor for more than three interviews. 1 2 3 4 5 6 7 Not Slightly Somewhat Fairly Quite Very Definitely True True True True True True True ___16. I EXPECT TO Never need counseling again. 1 2 3 4 5 6 7 Not Slightly Somewhat Fairly Quite Very Definitely True True True True True True True ___17. I EXPECT TO Enjoy being with the counselor. 1 2 3 4 5 6 7 Not Slightly Somewhat Fairly Quite Very Definitely True True True True True True True ___18. I EXPECT TO Stay in counseling even though it may be painful or unpleasant at times. 1 2 3 4 5 6 7 Not Slightly Somewhat Fairly Quite Very Definitely True True True True True True True ___19. I EXPECT TO Contribute as much as I can in terms of expressing my feelings and discussing them. 1 2 3 4 5 6 7 Not Slightly Somewhat Fairly Quite Very Definitely True True True True True True True ___20. I EXPECT TO See the counselor for only one interview. 1 2 3 4 5 6 7 Not Slightly Somewhat Fairly Quite Very Definitely True True True True True True True ___21. I EXPECT TO Go to counseling only if I have a very serious problem. 1 2 3 4 5 6 7 Not Slightly Somewhat Fairly Quite Very Definitely True True True True True True True ___22. I EXPECT TO Find that the counseling relationship will help the counselor and me to identify problems on which I need to work. 1 2 3 4 5 6 7 Not Slightly Somewhat Fairly Quite Very Definitely True True True True True True True ___23. I EXPECT TO Become better able to help myself in the future. 1 2 3 4 5 6 7 Not Slightly Somewhat Fairly Quite Very Definitely True True True True True True True ___24. I EXPECT TO Find that my problem will be solved once and for all in counseling. 1 2 3 4 5 6 7 Not Slightly Somewhat Fairly Quite Very Definitely 81

True True True True True True True ___25. I EXPECT TO Feel safe enough with the counselor to really say how I feel. 1 2 3 4 5 6 7 Not Slightly Somewhat Fairly Quite Very Definitely True True True True True True True ___26. I EXPECT TO See an experienced counselor. 1 2 3 4 5 6 7 Not Slightly Somewhat Fairly Quite Very Definitely True True True True True True True ___27. I EXPECT TO Find that all I need to do is answer the counselor’s questions. 1 2 3 4 5 6 7 Not Slightly Somewhat Fairly Quite Very Definitely True True True True True True Tru ___28. I EXPECT TO Improve my relationships with others. 1 2 3 4 5 6 7 Not Slightly Somewhat Fairly Quite Very Definitely True True True True True True True

___29. I EXPECT TO Ask the counselor to explain what he or she means whenever I do not understand something that is said. 1 2 3 4 5 6 7 Not Slightly Somewhat Fairly Quite Very Definitely True True True True True True True

___30. I EXPECT TO Work on my concerns outside the counseling interviews. 1 2 3 4 5 6 7 Not Slightly Somewhat Fairly Quite Very Definitely True True True True True True True

___31. I EXPECT TO Find that the interview is not the place to bring up personal problems. 1 2 3 4 5 6 7 Not Slightly Somewhat Fairly Quite Very Definitely True True True True True True True

For the next set of questions assess what you expect about the counselor. THE FOLLOWING QUESTIONS CONCERN YOUR EXPECTATIONS OF THE COUNSELOR ___32. I EXPECT THE COUNSELOR TO Explain what’s wrong. 1 2 3 4 5 6 7 Not Slightly Somewhat Fairly Quite Very Definitely True True True True True True True ___33. I EXPECT THE COUNSELOR TO Help me identify and label my feelings so I can better understand them. 1 2 3 4 5 6 7 Not Slightly Somewhat Fairly Quite Very Definitely True True True True True True True ___34. I EXPECT THE COUNSELOR TO Tell me what to do. 1 2 3 4 5 6 7 Not Slightly Somewhat Fairly Quite Very Definitely True True True True True True True ___35. I EXPECT THE COUNSELOR TO Know how I feel even when I cannot say quite what I mean. 1 2 3 4 5 6 7 Not Slightly Somewhat Fairly Quite Very Definitely True True True True True True True 82

___36. I EXPECT THE COUNSELOR TO Know how to help me. 1 2 3 4 5 6 7 Not Slightly Somewhat Fairly Quite Very Definitely True True True True True True True ___37. I EXPECT THE COUNSELOR TO Help me identify particular situations where I have problems. 1 2 3 4 5 6 7 Not Slightly Somewhat Fairly Quite Very Definitely True True True True True True True ___38. I EXPECT THE COUNSELOR TO Give encouragement and reassurance. 1 2 3 4 5 6 7 Not Slightly Somewhat Fairly Quite Very Definitely True True True True True True True ___39. I EXPECT THE COUNSELOR TO Help me to know how I am feeling by putting my feelings into words for me. 1 2 3 4 5 6 7 Not Slightly Somewhat Fairly Quite Very Definitely True True True True True True True ___40. I EXPECT THE COUNSELOR TO Be a “real” person not just a person doing a job. 1 2 3 4 5 6 7 Not Slightly Somewhat Fairly Quite Very Definitely True True True True True True True ___41. I EXPECT THE COUNSELOR TO Help me to discover what particular aspects of my behavior are relevant to my problems. 1 2 3 4 5 6 7 Not Slightly Somewhat Fairly Quite Very Definitely True True True True True True True ___42. I EXPECT THE COUNSELOR TO Inspire confidence and trust. 1 2 3 4 5 6 7 Not Slightly Somewhat Fairly Quite Very Definitely True True True True True True True ___43. I EXPECT THE COUNSELOR TO Frequently offer me advice. 1 2 3 4 5 6 7 Not Slightly Somewhat Fairly Quite Very Definitely True True True True True True True ___44. I EXPECT THE COUNSELOR TO Be honest with me. 1 2 3 4 5 6 7 Not Slightly Somewhat Fairly Quite Very Definitely True True True True True True True ___45. I EXPECT THE COUNSELOR TO Be someone who can be counted on. 1 2 3 4 5 6 7 Not Slightly Somewhat Fairly Quite Very Definitely True True True True True True True ___46. I EXPECT THE COUNSELOR TO Be friendly and warm towards me. 1 2 3 4 5 6 7 Not Slightly Somewhat Fairly Quite Very Definitely True True True True True True True ___47. I EXPECT THE COUNSELOR TO Help me solve my problems. 1 2 3 4 5 6 7 Not Slightly Somewhat Fairly Quite Very Definitely True True True True True True True ___48. I EXPECT THE COUNSELOR TO Discuss his or her own attitudes and relate them to my problem. 1 2 3 4 5 6 7 83

Not Slightly Somewhat Fairly Quite Very Definitely True True True True True True True ___49. I EXPECT THE COUNSELOR TO Give me support. 1 2 3 4 5 6 7 Not Slightly Somewhat Fairly Quite Very Definitely True True True True True True True ___50. I EXPECT THE COUNSELOR TO Decide what treatment plan is best. 1 2 3 4 5 6 7 Not Slightly Somewhat Fairly Quite Very Definitely True True True True True True True ___51. I EXPECT THE COUNSELOR TO Know how I feel at times, without my having to speak. 1 2 3 4 5 6 7 Not Slightly Somewhat Fairly Quite Very Definitely True True True True True True True ___52. I EXPECT THE COUNSELOR TO Do most of the talking. 1 2 3 4 5 6 7 Not Slightly Somewhat Fairly Quite Very Definitely True True True True True True True ___53. I EXPECT THE COUNSELOR TO Respect me as a person. 1 2 3 4 5 6 7 Not Slightly Somewhat Fairly Quite Very Definitely True True True True True True True ___54. I EXPECT THE COUNSELOR TO Discuss his or her experiences and relate them to my problems. 1 2 3 4 5 6 7 Not Slightly Somewhat Fairly Quite Very Definitely True True True True True True True ___55. I EXPECT THE COUNSELOR TO Praise me when I show improvement. 1 2 3 4 5 6 7 Not Slightly Somewhat Fairly Quite Very Definitely True True True True True True True ___56. I EXPECT THE COUNSELOR TO Make me face up to the differences between what I say and how I behave. 1 2 3 4 5 6 7 Not Slightly Somewhat Fairly Quite Very Definitely True True True True True True True ___57. I EXPECT THE COUNSELOR TO Talk freely about himself or herself. 1 2 3 4 5 6 7 Not Slightly Somewhat Fairly Quite Very Definitely True True True True True True True ___58. I EXPECT THE COUNSELOR TO Have no trouble getting along with people. 1 2 3 4 5 6 7 Not Slightly Somewhat Fairly Quite Very Definitely True True True True True True True ___59. I EXPECT THE COUNSELOR TO Like me. 1 2 3 4 5 6 7 Not Slightly Somewhat Fairly Quite Very Definitely True True True True True True True ___60. I EXPECT THE COUNSELOR TO Be someone I can really trust. 1 2 3 4 5 6 7 Not Slightly Somewhat Fairly Quite Very Definitely True True True True True True True ___61. I EXPECT THE COUNSELOR TO Like me in spite of bad things that he or she knows about me. 84

1 2 3 4 5 6 7 Not Slightly Somewhat Fairly Quite Very Definitely True True True True True True True ___62. I EXPECT THE COUNSELOR TO Make me face the differences of how I see myself and how I am seen by others. 1 2 3 4 5 6 7 Not Slightly Somewhat Fairly Quite Very Definitely True True True True True True True ___63. I EXPECT THE COUNSELOR TO Be someone who is calm and easygoing. 1 2 3 4 5 6 7 Not Slightly Somewhat Fairly Quite Very Definitely True True True True True True True ___64. I EXPECT THE COUNSELOR TO Point out to me the differences between what I am and what I want to be. 1 2 3 4 5 6 7 Not Slightly Somewhat Fairly Quite Very Definitely True True True True True True True ___65. I EXPECT THE COUNSELOR TO Just give me information. 1 2 3 4 5 6 7 Not Slightly Somewhat Fairly Quite Very Definitely True True True True True True True ___66. I EXPECT THE COUNSELOR TO Get along well in the world. 1 2 3 4 5 6 7 Not Slightly Somewhat Fairly Quite Very Definitely True True True True True True True

APPENDIX B: THOUGHTS ABOUT PSYCHOTHERAPY SURVEY

In filling out the following survey, we would like you to imagine that you have decided to see a therapist for a personal problem. Please answer the following questions by circling a number below:

1. Is psychotherapy what I need to help me with my problems? 1 2 3 4 5 I would not be I would be very concerned about this concerned about this

2. Will I be treated more as a case than as a person in psychotherapy? 1 2 3 4 5 I would not be I would be very concerned about this concerned about this

3. Will the therapist be honest with me? 1 2 3 4 5 I would not be I would be very concerned about this concerned about this

4. Will the therapist take my problems seriously? 1 2 3 4 5 I would not be I would be very concerned about this concerned about this

5. Will the therapist share my values? 1 2 3 4 5 I would not be I would be very concerned about this concerned about this

6. Will everything I say in psychotherapy be kept confidential? 1 2 3 4 5 I would not be I would be very concerned about this concerned about this

7. Will the therapist think I'm a bad person if I talk about everything I have been thinking and feeling? 1 2 3 4 5 I would not be I would be very concerned about this concerned about this

8. Will the therapist understand my problem? 1 2 3 4 5 I would not be I would be very concerned about this concerned about this

9. Will my friends think I'm abnormal or weird for coming? 1 2 3 4 5 I would not be I would be very concerned about this concerned about this

10. Will the therapist think I'm more disturbed than I am? 86

1 2 3 4 5 I would not be I would be very concerned about this concerned about this

11. Will the therapist find out things I don't want him/her to know about me and my life? 1 2 3 4 5 I would not be I would be very concerned about this concerned about this

12. Will I learn things about myself I don't really want to know? 1 2 3 4 5 I would not be I would be very concerned about this concerned about this

13. Will I lose control of my emotions while in psychotherapy? 1 2 3 4 5 I would not be I would be very concerned about this concerned about this

14. Will the therapist be competent to address my problem? 1 2 3 4 5 I would not be I would be very concerned about this concerned about this

15. Will I be pressured to do things in psychotherapy I don't want to do? 1 2 3 4 5 I would not be I would be very concerned about this concerned about this

16. Will I be pressured to make changes in my lifestyle that I feel unwilling or unable to make right now? 1 2 3 4 5 I would not be I would be very concerned about this concerned about this

17. Will I be pressured into talking about things that I don't want to? 1 2 3 4 5 I would not be I would be very concerned about this concerned about this

18. Will I end up changing the way 1 think or feel about things or the world in general? 1 2 3 4 5 I would not be I would be very concerned about this concerned about this

19. Seeing a therapist would cause me to worry, experience nervousness or feel fearful in general.

1 2 3 4 5 I would not be I would be very concerned about this concerned about this 87

APPENDIX C: ATTITUDES TOWARD SEEKING PROFESSIONAL

PSYCHOLOGICAL HELP

Please circle the number corresponding to your level of agreement with the following statements.

1. If I believed I was having a mental breakdown, my first inclination would be to get professional help. Agree Partly Agree Partly Disagree Disagree 0 1 2 3 2. The idea of talking about problems with a therapist strikes me as a poor way to get rid of emotional conflicts. Agree Partly Agree Partly Disagree Disagree 0 1 2 3 3. If I were experiencing a serious emotional crisis at this point in my life, I would be confident that I could find relief in therapy. Agree Partly Agree Partly Disagree Disagree 0 1 2 3 4. There is something admirable in the attitude of a person willing to cope with his or her conflicts and fears without resorting to therapy. Agree Partly Agree Partly Disagree Disagree 0 1 2 3 5. I would want to go to a therapist if I were worried or upset for a long period of time. Agree Partly Agree Partly Disagree Disagree 0 1 2 3 6. I might want to see a therapist in the future. Agree Partly Agree Partly Disagree Disagree 0 1 2 3 7. A person with an emotional problem is not likely to solve it alone; he or she is likely to solve the problem with the help of a therapist. Agree Partly Agree Partly Disagree Disagree 0 1 2 3 8. Considering the time and expense involved in therapy, it would have doubtful value for a person like me. Agree Partly Agree Partly Disagree Disagree 0 1 2 3 9. A person should work out his or her own problems; seeing a therapist would be a last resort. Agree Partly Agree Partly Disagree Disagree 0 1 2 3 10. Personal and emotional troubles, like many things, tend to work out by themselves. Agree Partly Agree Partly Disagree Disagree 0 1 2 3

APPENDIX D: INTENTIONS TO SEEK COUNSELING INVENTORY

Please rate the likeliness that you would see a therapist if you were experiencing one of the following.

1. Weight control 1 2 3 4 5 6 Very Unlikely Very Likely 2. Excessive alcohol use 1 2 3 4 5 6 Very Unlikely Very Likely 3. Relationship difficulties 1 2 3 4 5 6 Very Unlikely Very Likely 4. Concerns about sexuality 1 2 3 4 5 6 Very Unlikely Very Likely 5. Depression 1 2 3 4 5 6 Very Unlikely Very Likely 6. Conflicts with parents 1 2 3 4 5 6 Very Unlikely Very Likely 7. Speech anxiety 1 2 3 4 5 6 Very Unlikely Very Likely 8. Dating difficulties 1 2 3 4 5 6 Very Unlikely Very Likely 9. Choosing a major 1 2 3 4 5 6 Very Unlikely Very Likely 10. Difficulty in sleeping 1 2 3 4 5 6 Very Unlikely Very Likely 11. Drug problems 1 2 3 4 5 6 Very Unlikely Very Likely 12. Inferiority feelings 1 2 3 4 5 6 Very Unlikely Very Likely 13. Test anxiety 1 2 3 4 5 6 Very Unlikely Very Likely 14. Difficulties with friends 1 2 3 4 5 6 Very Unlikely Very Likely 15. Academic work procrastination 1 2 3 4 5 6 Very Unlikely Very Likely 16. Self-understanding 1 2 3 4 5 6 Very Unlikely Very Likely 17. Loneliness 1 2 3 4 5 6 Very Unlikely Very Likely

APPENDIX E: STIGMA SCALE FOR RECEIVING PSYCHOLOGICAL HELP

Please rate your level of agreement with the following:

1. Seeing a therapist for emotional or interpersonal problems carries social stigma. Strongly Disagree Disagree Agree Strongly Agree 0 1 2 3 2. It is a sign of a personal weakness or inadequacy to see a therapist for emotional problems. Strongly Disagree Disagree Agree Strongly Agree 0 1 2 3 3. People will see a person in a less favorable way if they know that he/she has seen a therapist. Strongly Disagree Disagree Agree Strongly Agree 0 1 2 3 4. It is advisable for a person to hide from people that he/she is in therapy. Strongly Disagree Disagree Agree Strongly Agree 0 1 2 3 5. People tend to like those who are in therapy. Strongly Disagree Disagree Agree Strongly Agree 0 1 2 3

APPENDIX F: TRANSPORTATION SCALE

Please circle the number corresponding to your level of agreement with the following statements.

1. While I was watching the program, I could easily picture the events in it taking place. Strongly Agree 1 2 3 4 5 6 7 Strongly Disagree

2. While I was watching the program, activity going in the room around me was on my mind. Strongly Agree 1 2 3 4 5 6 7 Strongly Disagree

3. I could picture myself in the scene of events in the story. Strongly Agree 1 2 3 4 5 6 7 Strongly Disagree

4. I was mentally involved in the story while watching it. Strongly Agree 1 2 3 4 5 6 7 Strongly Disagree

5. After finishing the program, I found it easy to put it out of my mind. Strongly Agree 1 2 3 4 5 6 7 Strongly Disagree

6. I wanted to learn how the program ended. Strongly Agree 1 2 3 4 5 6 7 Strongly Disagree

7. The program affected me emotionally. Strongly Agree 1 2 3 4 5 6 7 Strongly Disagree

8. I found myself thinking of ways the program could have turned out differently. Strongly Agree 1 2 3 4 5 6 7 Strongly Disagree

9. I found my mind wandering while watching the program. Strongly Agree 1 2 3 4 5 6 7 Strongly Disagree

10. The events in the program are relevant to my everyday life. Strongly Agree 1 2 3 4 5 6 7 Strongly Disagree

11. The events in the program have changed my life. Strongly Agree 1 2 3 4 5 6 7 Strongly Disagree

APPENDIX G: NARRATIVE ENGAGEMENT SCALE

Please circle the number corresponding to your level of agreement with the following statements.

1. At points, I had a hard time making sense of what was going on in the program. Strongly Agree 1 2 3 4 5 6 7 Strongly Disagree

2. My understanding of the characters is unclear. Strongly Agree 1 2 3 4 5 6 7 Strongly Disagree

3. I had a hard time recognizing the thread of the story. Strongly Agree 1 2 3 4 5 6 7 Strongly Disagree

4. I found my mind wandering while the program was on. Strongly Agree 1 2 3 4 5 6 7 Strongly Disagree

5. While the program was on I found myself thinking about other things. Strongly Agree 1 2 3 4 5 6 7 Strongly Disagree

6. I had a hard time keeping my mind on the program. Strongly Agree 1 2 3 4 5 6 7 Strongly Disagree

7. During the program, my body was in the room, but my mind was inside the world created by the story. Strongly Agree 1 2 3 4 5 6 7 Strongly Disagree

8. The program created a new world, and then that world suddenly disappeared when the program ended. Strongly Agree 1 2 3 4 5 6 7 Strongly Disagree

9. At times during the program, the story world was closer to me than the real world. Strongly Agree 1 2 3 4 5 6 7 Strongly Disagree

10. The story affected me emotionally. Strongly Agree 1 2 3 4 5 6 7 Strongly Disagree

11. During the program, when a main character succeeded, I felt happy, and when they suffered in some way, I felt sad. Strongly Agree 1 2 3 4 5 6 7 Strongly Disagree

12. I felt sorry for some of the characters in the program. Strongly Agree 1 2 3 4 5 6 7 Strongly Disagree

APPENDIX H: SELF-SURVEY

Please circle one of the number’s below As a portrayal of psychotherapy, I would rate this as 1 ------2 ------3 ------4 ------5 ------6 ------7 Negative Positive 1 ------2 ------3 ------4 ------5 ------6 ------7 Unrealistic Realistic

As a portrayal of a psychotherapist, I would rate this as 1 ------2 ------3 ------4 ------5 ------6 ------7 Negative Positive 1 ------2 ------3 ------4 ------5 ------6 ------7 Unrealistic Realistic

I believe that overall, after watching this, someone will be 1 ------2 ------3 ------4 ------5 ------6 ------7 Less likely to seek therapy More likely to seek therapy

I believe that overall, after watching this, I would be

1 ------2 ------3 ------4 ------5 ------6 ------7 Less interested in therapy More interested in therapy

APPENDIX I: DEMOGRAPHICS QUESTIONNAIRE

Identified Gender: Male (2) Female (1) Circle one

Age______please specify

Year in College: Circle one First Year (1) Sophomore (2) Junior (3) Senior (4)

College Major______please specify (“undeclared” if you have not chosen one)

Identified Race: Circle one Caucasian (1) African American (2) Hispanic (3) Asian (4)

Native American (5) Other (6): ______please specify

Marital Status: Circle one Single (1) Committed Relationship (2) Married (3) Separated (4) Divorced (5)

Have you ever sought professional psychological help (presently or in the past)? Circle one

YES(1) No(2)

If yes, for what type of problem did you seek services? ______

If yes, how helpful did you find your experience with professional psychological services?

Very unhelpful unhelpful somewhat helpful helpful very helpful 1 2 3 4 5

Would you recommend professional psychological services to others?

Very unlikely unlikely somewhat likely likely very likely 1 2 3 4 5

Approximately how many hours (per week) do you spend on the following? Circle one Watching television on cable (1-5) (5-10) (10-20) (20-30) (30+) Watching television online (1-5) (5-10) (10-20) (20-30) (30+) Watching movies/films (1-5) (5-10) (10-20) (20-30) (30+) Watching movies/films online (1-5) (5-10) (10-20) (20-30) (30+) Surfing the internet (1-5) (5-10) (10-20) (20-30) (30+)

APPENDIX J: CONSENT FORM

Ohio University Research Consent Form

Title of Research: Perception of Narratives in Popular Television

Researcher: Troy Robison M.S.

You are being asked to participate in research. For you to be able to decide whether you want to participate in this project, you should understand what the project is about, as well as the possible risks and benefits in order to make an informed decision. This process is known as informed consent. This form describes the purpose, procedures, possible benefits, and risks. It also explains how your personal information will be used and protected. Once you have read this form and your questions about the study are answered, you will be asked to sign it. This will allow your participation in this study. You should receive a copy of this document to take with you.

EXPLANATION OF STUDY

This study is being done in order to examine the perception of university undergraduates regarding interpersonal and dramatic elements from popular television.

If you agree to participate, you will be asked to view television portrayals of psychotherapy. As a method of standardizing the stimulus used in the study all portrayals of contain segments of an interpersonal relationship in a psychotherapeutic setting. You will then be completing a number of questionnaires about the clips that were seen.

Your participation in the study will last approximately 90 minutes.

Risks and Discomfort

Risks or discomforts that you might experience are only those that might come from viewing popular films. You should not participate in this study if you feel uncomfortable watching television clips rated TV-MA that contain strong or sexual language. Benefits

You will help advance research in this area of psychology and science more generally, as well as gain experience and knowledge about the research process.

Confidentiality and Records

Your study information will be kept confidential and will not be shared with anyone outside of the study. Your name will not appear in any reports about the study. All personal information gathered in this study will only be used by the principal investigator for research purposes.

Your Ohio ID will be collected in order to tie information obtained during the prescreen to you. Once the prescreen data is linked to the data you provide today, your Ohio ID will be stripped from the data by June 15, 2012.

Additionally, while every effort will be made to keep your study-related information confidential, there may be circumstances where this information must be shared with: * Federal agencies, for example the Office of Human Research Protections, whose responsibility is to protect human subjects in research; * Representatives of Ohio University (OU), including the Institutional Review Board, a committee that oversees the research at OU;

Compensation As compensation for your time/effort, you will receive 2.0 hours of the required course credit needed by the psychology department at Ohio University for participating in psychological research. If you choose to withdraw from the study during the first hour, you will only receive 1.0 credit. Contact Information

If you have any questions regarding this study, please contact Troy Robison Department of Psychology, Ohio University, (740) 593 -0106 or email at [email protected] Advisor: Ben Ogles, Dean, College of Family, Home, and Social Sciences, 990-C SWKT, [email protected].

If you have any questions regarding your rights as a research participant, please contact Jo Ellen Sherow, Director of Research Compliance, Ohio University, (740)593-0664.

By signing below, you are agreeing that: • you have read this consent form (or it has been read to you) and have been given the opportunity to ask questions and have them answered • you have been informed of potential risks and they have been explained to your satisfaction. • you understand Ohio University has no funds set aside for any injuries you might receive as a result of participating in this study • you are 18 years of age or older • your participation in this research is completely voluntary • you may leave the study at any time. If you decide to stop participating in the study, there will be no penalty to you and you will not lose any benefits to which you are otherwise entitled.

Signature Date

Printed Name

Version Date: 12/11/11

APPENDIX K: DEBRIEFING FORM

Title of Research: The Impact of Television Portrayals of Psychotherapy on Viewer’s Expectations of Outcome and Likelihood to Seek Therapeutic Treatment.

Principal Investigator: Troy Robison - Department of Psychology, Ohio University

Explanation of Study The purpose of this study was to determine the impact of portrayals of psychotherapy in popular media. Specifically of interest is the impact of these portrayals on participant’s expectations of what occurs during psychotherapy and whether or not these portrayals impact the likelihood that one will seek psychotherapy as viable treatment option for various problems.

Risks and Discomforts If there was some level of emotional or mental discomfort associated with your participation in the study or completion of psychological measures there are university resources available to students.

Counseling and Psychological Services Hudson Health Center, 3rd Floor 2 Health Center Drive Telephone: (740) 593-1616 Email: [email protected]

Psychology & Social Work Clinic 002 Porter Hall Telephone; (740) 593-0902

Confidentiality and Records All identifying information collected in the study will be used only by the researcher to match the answers on the most recent measures with similar items that were completed as part of the mass psychology screener that was completed prior to participation today. Once the data has been linked, all personal identifying information will be deleted from the records and will not be provided in any way for subsequent research, contact, or publications.

Compensation For your participation in the study you will be given 2.0 hours of the required course credit needed by the psychology department at Ohio University for participating in psychological research.

Contact Information If you have any questions regarding this study, please contact Troy Robison, Department of Psychology, Ohio University, (740) 593-0106 or email at [email protected] 97

If you have any questions regarding your rights as a research participant, please contact Jo Ellen Sherow, Director of Research Compliance, Ohio University, (740)593-0664.

APPENDIX L: STUDY INSTRUCTIONS

Have Participants Sign in Have them sit with one seat between each other for privacy.

Welcome to the study. “Today we are asking you to rate the narrative communication on fictional television portrayals. You will be watching several clips spliced together to form a coherent story. These clips are sometimes spaced apart by black screen and only audio, this is a product of the editing software and please don’t pay attention to it.”

Hand out the Consent Form “Please read and sign this consent form. When you are finished please turn it back in to the researcher.”

Handout the Narrative Quiz “Please look over this packet. Take a few minutes to complete the second and third pages. When you are finished, please turn to the first page and you will be completing this quiz on the material you will view today during the portrayal. You will be keeping this during the clips.”

START THE VIDEO Remind them to put away and turn off cell phones or other devices during the show.

Hand out the packet. “Please read and answer each question carefully. Then turn the packet in at the front when you leave. Once you have completed the packet, your participation is complete.”

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