Pre-treatment consent framing shapes how laypeople evaluate CBT: a cross-cultural comparison of China and the United States

Abstract

People’s understanding of psychotherapy influences their treatment expectations and engagement. Informed consent is often one of the first formal processes through which this understanding is shaped. Yet, little cross-cultural research has examined its impact on lay people’s pre-treatment attitudes. This study investigated whether the perceived importance of common factors and cognitive behavioral therapy (CBT) techniques varies across cultural contexts and informed consent framing. Chinese (n = 297) and U.S. (n = 303) participants with no prior therapy experience were randomly assigned to standard CBT framing, enhanced framing that added information about common factors, or a non-framing (vignette-only) condition. They then used a 5-point Likert-type response format to rate the perceived importance of five elements for the success of CBT: empathy, working alliance, unconditional positive regard, expectancy, and CBT-specific techniques. Analyses combined ANOVA, Bayesian network analysis, and inter-subject representational similarity analysis (IS-RSA) to examine mean differences, attitude system structure, and individual profile similarity. Results indicated that culture influenced four of the five importance ratings. Chinese participants rated empathy and positive regard as more important, whereas U.S. participants rated working alliance and CBT techniques as more important (ps < 0.05). Attitude networks showed comparable global connectivity (ΔM = −0.254), although the empathy–positive regard association was stronger in the Chinese network. Enhanced framing produced higher importance ratings for empathy than standard framing, while standard framing produced higher ratings for CBT techniques (ps < 0.01). IS-RSA revealed that shared consent framing was more strongly associated with attitude profile similarity than shared cultural background (ρconsent = 0.033, ρculture = 0.016), with the consent effect approximately twice the magnitude of the culture effect. Lay attitudes toward psychotherapy are affected by both cultural context and how treatment is initially presented. Informed consent may therefore serve an important communicative function that influences which therapy elements prospective clients view as important.