A surprise might do you good 

It’s hardly surprising that if you go into therapy with a genuine hope of a positive result, you’re more likely to emerge with exactly that – and the opposite is also true. So a negative or pessimistic outlook is more likely in clients whose outcomes are poorer.

But a group of Canadian cognitive behaviour therapists wanted to know more than this; they wanted to explore clients’ expectations, and specifically, whether these expectations matched their actual experiences of therapy. And more importantly, they wanted to see if this had any link to the results and effects, after therapy was complete [1].

The research project

Nine ‘good-outcome’ clients and nine ‘poor-outcome’ clients were chosen for comparison. All were asked a series of questions designed to reveal in some detail what they had felt about therapy before, during and after treatment. Questions focussed on the therapist’s role, what they felt were the most and least helpful aspects of their sessions, and how comfortable they had felt. They were then asked how closely any of this matched their previous expectations. 

The results

Results fell into two categories – ‘therapy was not what I expected’ and ‘therapy was what I expected’ , with categories each containing sub-sections. So therapy can bring about a ‘pleasant surprise’ feeling, or a disappointed one, if expectations are not met; in the second category, therapy could match high expectations by being a good experience, or low ones by being a poor one. The most common answers showed that clients were in fact surprised by at least some of their experiences, either positively or negatively….but it was the ‘pleasant surprise’ clients that did better at the end of therapy. 

The results showed that ‘good-outcome’ clients were firmly in that ‘pleasantly surprised’ camp – often surprised that they were able to work with the therapist and to take the lead at times, and more comfortable with the whole process than they thought they would be. Poor-outcome clients generally reported disappointment or that low expectations were confirmed. Good-outcome clients also reported gaining more from treatment than expected.

The theory behind it

The theoretical underpinnings informing this study come from the theory of ‘expectancy violation’ which holds that surprise experiences in communications have an impact on further interactions – so if someone behaves in a way you don’t expect, it effects the way you relate to them in the future. In addition, ‘decision affect theory’ proposes that pleasantly surprising experiences are inevitably more pleasurable than the ones you knew were going to happen all along.

So it seems that you’re more likely to make the most of CBT if you keep your expectations low or neutral – and then find things are not as bad, or rather better, than you thought. Spot the implications though: does this mean that a well-informed client, who’s read something about CBT and who knows what to expect, is less likely to benefit? And that keeping clients in the dark about what happens in therapy gives the best results? 

Reference

1. Therapy was not what I expected: a preliminary qualitative analysis of concordance between client expectations and experience of cognitive-behavioural therapy. by Henny Alice Westra, Adi Aviram, Marissa Barnes, Lynne Angus