Believing is Seeing
Clinical Implications of Research on Patient Expectations
A classic social psychological finding is that expectations shape people’s experiences, perceptions, and behaviors (e.g., Asch, 1946). Clinical psychologists have long been interested in how expectations specifically affect psychotherapy (e.g., Frank, 1968). After decades of theoretical and empirical attention, it appears safe to say that patient expectations are an important ingredient of psychotherapeutic change (e.g., Kirsch, 1990). Here we briefly discuss types of expectations, empirical findings on expectations, and empirically-informed clinical strategies for assessing, fostering, and responding to patient expectations in treatment.
Patient expectations can be categorized into two main groups: outcome and treatment. Outcome expectations reflect prognostic beliefs about a treatment’s utility (Arnkoff, Glass, & Shapiro, 2002). Such expectancies may exist before treatment, may be influenced by early contact with a provider, and/or may be closely linked with the perceived credibility of a psychotherapist or psychotherapy approach. Treatment expectations reflect beliefs about what will transpire during treatment and can be subdivided into role and process (Arnkoff et al., 2002). Role expectations refer to patients’ beliefs about how they (e.g., talking about the past) and their psychotherapist (e.g., providing emotional support) will behave, while process expectations involve beliefs about the treatment’s type (e.g., problem-oriented) and duration (e.g., long-term).
Reviews reveal that patients’ outcome expectations are consistently associated with clinical improvement across various treatments and conditions (e.g., Greenberg, Constantino, & Bruce, 2006). More recently, several studies have revealed a positive correlation between patients’ outcome expectations and therapeutic alliance quality (e.g., Constantino, Arnow, Blasey, & Agras, 2005). Other studies have found that alliance quality mediates the relationship between outcome expectations and post-treatment gains (e.g., Meyer et al., 2002). Recent developments also highlight important interactions between patient expectations and psychotherapist characteristics. For example, Ahmed and Westra (2007) found that analogue patients high in change expectations had better outcomes, but only when hearing a treatment rationale provided by a warm and enthusiastic clinician. The opposite was found for those with low change expectations who demonstrated good outcomes only when hearing the rationale from a colder and less enthusiastic counselor. These findings speak to the importance of psychotherapists responding to their patients’ change expectations, and that matching on level of enthusiasm and optimism for change may be an initially helpful exchange.
Reviews have also implicated treatment expectations as important determinants of adaptive psychotherapy processes and outcomes (e.g., Greenberg et al., 2006). For example, Joyce and Piper (1998) found that greater discrepancies between patients’ expectations of a typical session and what they actually experienced were associated with poorer alliance ratings. Also, Schneider and Klauer (2001) found that patients who expected to be actively involved in treatment evidenced greater improvement than patients with lower expectations for active involvement. Finally, a robust finding is that the longer patients expect treatment to last, the longer they actually participate (e.g., Jenkins, Fuqua, & Blum, 1986).
Despite its empirical support, the expectancy construct has been traditionally undervalued across all psychotherapy orientations (Greenberg et al., 2006). Furthermore, although many treatments address patient expectations in some manner, expectancy strategies are often neither explicit nor systematic. Thus, it seems important for clinicians to heed the expectancy literature and, if they have not already, incorporate expectancy-based strategies into their clinical repertoires. We offer below sample clinical strategies.
First, clinicians should explicitly assess patients’ expectations at the treatment’s launch. The nature of patients’ outcome expectations should also inform the psychotherapist’s initial stance. As noted above, initially matching patients at their level of enthusiasm and optimism may be a verifying and helpful process. Furthermore, psychotherapists need to understand their patients’ expectations for role behaviors and personal philosophies of change. To the extent that role behaviors or treatment strategies are incompatible with patients’ beliefs, clinicians may need to work toward changing their patients’ expectations via preparatory socialization strategies and/or, if appropriate, alter the nature of treatment to better meet patients’ expectations.
Second, although initially meeting patients’ expectations may prove verifying and useful, many psychotherapies adopt the assumption that modifying expectations reflects an important change process. Thus, while working hard not to invalidate a patient’s experience, clinicians should also work toward fostering more positive expectations. For example, psychotherapists should make a concerted effort to offer personalized hope-inspiring statements at the treatment’s outset (e.g., “You strike me as someone who can really accomplish the things that you put your mind to and your being here suggests to me that you have put your mind to it.”) (Constantino, Klein, & Greenberg, 2006). Clinicians may also offer a nontechnical review of the supporting empirical literature for the treatment they intend to employ (if it exists) in order to build credibility, hope, and positive prognostications (e.g., “A lot of research has demonstrated that people who engage in cognitive therapy for depression tend to get significantly better than people who try simply to ‘deal with’ their difficulties on their own.”) (Constantino et al., 2006).
Third, expectations are not just a pre- or early-treatment phenomenon. Patients’ outcome expectations may vary over the treatment course, and their treatment expectations may change. Thus, psychotherapists should regularly check-in on their patients’ expectations and respond appropriately to either unrealistically high expectations (e.g., congratulating, yet reminding a depressed person of depression’s recurrent nature) or diminishing hope (e.g., reminding a depressed person that change is gradual, yet also helping to draw on past successes for future-oriented inspiration) (Constantino et al., 2006).
In adopting expectancy assessment, enhancement, and responsiveness strategies, clinicians may be assisted by using one or more of the psychometrically sound measures that exist. For example, the Credibility/Expectancy Questionnaire (CEQ; Devilly & Borkovec, 2000) assesses treatment credibility and outcome expectations. The Psychotherapy Expectancy Inventory-Revised (PEI-R; Bleyen, Vertommen, Vander Steene, & Van Audenhove, 2001) assesses treatment expectancies. Very specific expectancy scales also exist. For example, Dozois and Westra (2005) have developed the Anxiety Change Expectancy Scale (ACES). All of these scales are printed in the primary references listed above.
With the wealth of empirical support, the development of valid measures, and the outlining of clinical heuristics, the time seems ripe for the expectancy construct to shed is label as the most ignored common treatment factor (Weinberger & Eig, 1999), and for psychotherapists to take advantage of its powerful influence.
Cite This Article
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