University of Massachusetts Amherst

A voluminous and ever-expanding research literature points to the general effectiveness of psychotherapy (Lambert & Ogles, 2004). Through the use of controlled clinical trials, psychotherapy researchers have identified many empirically-supported treatments for specific clinical phenomena (Roth & Fonagy, 2005). The extant research also suggests that, with just a few exceptions, different therapy modalities yield comparable clinical effects (Lambert & Ogles, 2004). From a glass-half-full perspective, the field has made impressive strides in legitimizing the power of psychosocial interventions. Furthermore, as reflected in the long-standing “Dodo bird” interpretation of the comparative outcome literature, it can be asserted that everybody has indeed won and all should have prizes.

From a glass-half-empty perspective, psychotherapy’s general effectiveness is tempered by its clear limitations. For example, effective treatments for some psychological conditions have yet to be established, and the generalizability to everyday practice of treatments tested in controlled efficacy contexts remains tenuous. Furthermore, even when provided the “gold standard” treatment for a particular condition, some patients fail to respond, only partially respond, or respond but relapse; others drop out of treatment or even deteriorate (Lambert & Ogles, 2004). Thus, it seems that the Dodo verdict can be reconsidered to suggest that all therapies can be improved (Castonguay, Reid, Halperin, & Goldfried, 2003).

Although efforts toward improvement can come in many shapes and sizes, some scholars have argued that improvement may perhaps best be achieved through (a) theoretical humility and openness to the contributions of other (and perhaps historically incompatible or rival) orientations (e.g., Castonguay et al., 2003), and (b) treatment modifications based on process research (e.g., Grawe, 1997). Such approaches preserve the field’s advances in empirically supporting certain treatment packages, while inherently recognizing the complexity of change and the need to move forward creatively in refining treatments to both embrace and address such complexities.

Both of the aforementioned pathways to improvement reflect a specific model of psychotherapy integration (see Norcross & Goldfried, 2005). The former captures assimilative integration, or the attempt to improve an established system of psychotherapy by carefully considering the potential contributions of other systems. The latter captures common factors integration, which focuses on the conceptual and empirical contributions of pantheoretical and pandiagnostic therapeutic ingredients, and the inevitable influence of the momentary and dynamic context on the treatment process.

Among others, process research has persuasively implicated two common factors in the change process – the therapeutic alliance and patient expectations (see Castonguay, Constantino, & Holtforth, 2006; Greenberg, Constantino, & Bruce, 2006). To date, a facet of my research program has been directed at developing, systematizing, and experimentally testing alliance and expectancy-based treatment modules as a means to improve the efficacy of a particular empirically-established treatment (i.e., cognitive therapy; CT) for a specific condition (i.e., adult major depressive disorder; MDD). Although CT is an efficacious treatment for depression, recent estimates from controlled trials suggest that over half of MDD patients do not remit at posttreatment (De Matt, Dekker, Schoevers, & De Jonghe, 2006), while an even higher percentage fail to maintain lasting improvements (Hollon et al., 2005). Thus, there is room for significant improvement in CT for depression, and there remains a pressing need to refine treatments to increase response and decrease relapse. My collaborators and I have embarked on two such efforts. The alliance-based effort focuses on incorporating humanistic and interpersonal alliance-rupture repair strategies into standard CT and, thus, fits the assimilative and common factors models. The expectancy-based effort focuses on incorporating into CT systematic and responsive efforts to foster, manage, and change patients’ treatment expectations, which follows the common factors pathway. Below I describe each research line, including (a) a brief review of process findings that led to the treatment development, (b) a brief overview of the treatment module, and (c) a summary of our preliminary research to date.

Therapeutic Alliance Process Research and Integrative Cognitive Therapy

Pantheoretically defined, the therapeutic alliance reflects the quality of the patient-therapist working collaboration and affective bond (Bordin, 1979). As reflected in our own reviews and process-outcome studies (e.g., Constantino, Arnow, Blasey, & Agras, 2005; Constantino, Castonguay, & Schut, 2002), the alliance is a well-established predictor of treatment success across a variety of psychotherapies and presenting problems. The alliance not only predicts outcome, but it also provides a dynamic context for the implementation and utility of other interventions. For example, in a study of CT for depression, Castonguay, Goldfried, Wiser, Raue, and Hayes (1996) found that strict therapist adherence to prescribed CT techniques in the context of an alliance rupture was negatively related to outcome. Inspired by these findings, and guided by an assimilative integration model, Castonguay (1996) developed Integrative Cognitive Therapy (ICT), which is an approach to depression that remains grounded in CT but systematically incorporates humanistic and interpersonal strategies for identifying, addressing, and repairing emergent alliance ruptures.

Based on the contributions of Burns (1989) and Safran and Segal (1990), ICT presupposes that CT therapists can be more effective in dealing with alliance strains by exploring the source of the difficulty (including their own contributions) rather than increasing their adherence to core CT interventions. In this vein, the ICT manual outlines a 3-step rupture-repair sequence in which the therapist: (1) Invites the patient to discuss his negative reaction to the therapy or therapist; (2) Empathizes with the patient’s feelings and invites additional emotional disclosure in the service of understanding, respecting, and validating the patient’s subjective experience; and (3) Disarms the patient’s antagonism, anger, and/or other negative feelings by acknowledging his or her own contribution to the rupture. Such action promotes a restoration or enhancement of the collaborative working relationship, at which time the therapist then resumes standard CT techniques.

In an initial pilot investigation of ICT, Castonguay et al. (2004) found that ICT produced significantly superior outcomes than a wait-list control condition. As a follow-up, my research team conducted a pilot study (Constantino et al., 2008) to test further ICT’s efficacy and specificity by directly comparing it to standard CT. In this sense, the study employed an additive design, the strength of which resides in its high level of control across the independent treatment variable (e.g., Behar & Borkovec, 2003). With the exception of ICT’s additional rupture-repair strategies, the treatments were delivered according to the same CT protocol, thereby reducing the likelihood that outcome differences are a function of “nonspecific” factors and strengthening the causal inferences that can be made about the alliance manipulations. Furthermore, by using CT-as-usual as a control group, the additive design (a) transcends the specific versus common factors debate by assessing whether rupture-repair interventions work additively or synergistically to improve an already established treatment package, and (b) adds a cause-and-effect dimension to the alliance-outcome link. In our study, using clinicians-in-training, we found preliminary evidence that ICT could be distinguished from CT, and that ICT outperformed CT (small to medium effects) in terms of reducing depressive and global symptomatology. Furthermore, relative to CT, there were fewer dropouts, higher quality alliances, and higher perceived therapist empathy in ICT (medium to large effects). Thus, ICT may be considered a promising limited support treatment (Roth & Fonagy, 1996) worthy of future rigorous study.

Although preliminary, our emerging ICT findings suggest that psychotherapists should not only strive to foster good initial alliances with their patients, but also constantly assess for any deviations in the relationship climate. In the face of potential or actual alliance ruptures, clinicians should resist rigid adherence to the techniques they have been employing (e.g., standard CT interventions) and work through such relationship issues directly, openly, and nondefensively. The use of gentle probing, active listening, empathizing, and disarming may not only help to get the relationship back on track, but such metacommunication strategies may also promote a corrective relational experience (see also Safran & Muran, 2000).

Expectancy Process Research and the Expectancy Enhancement Treatment Module

Patients’ expectations have long been considered a common treatment factor (e.g., Frank, 1961). Outcome expectations refer to a prognostic belief that therapy will help, while process expectations reflect beliefs about what will transpire during therapy. As reflected in our own review and process-outcome studies (e.g., Constantino et al., 2007; Greenberg et al., 2006), expectations have been shown to be important contributors to adaptive during- and post-treatment outcomes. However, the expectation construct has been remarkably undervalued (Weinberger & Eig, 1999). Although many therapies include elements that address patient expectations in some manner, expectancy strategies are often neither explicit nor systematic. Moreover, in experimental treatment studies, expectations have been traditionally viewed as artifacts to be controlled – a perspective that now seems outdated. Thus, we have developed a treatment manual that outlines an explicit and systematic approach to enhancing patient expectations about therapeutic change and the treatment course.

The expectancy enhancement (EE) manual (Constantino, Klein, & Greenberg, 2006) addresses pre- and during-treatment expectations. Specifically, it comprises (a) an initial session EE interview to enhance patients’ outcome expectations and their expectations about the length and nature of treatment, (b) ongoing standard and reactive EE strategies, (c) general relationship strategies to be considered in light of patients’ expectations, and (d) a termination component that aims to enhance patients’ posttreatment expectations for maintaining their treatment gains. The present version of EE was designed as a companion manual to CT for depression. However, we suspect that such strategies can eventually be adapted for a wide range of clinical conditions and for other treatment modalities. We are currently conducting another pilot study, again utilizing an additive design, to foster the development of the EE manual and to test preliminarily its causative enhancement of standard CT. Although the outcome data are still forthcoming, we have been able to successfully train graduate trainees on the protocol, and they have been able to implement the treatment with good fidelity and competence.

Despite not yet having data on the specific efficacy of our EE manual, psychotherapy process research points consistently to the clinical importance of patients’ process and outcome expectations. Moreover, most psychotherapies involve some level of manipulation, exploration, challenge, and/or revision of patient expectations (Greenberg et al., 2006). Thus, clinicians should carefully assess patients’ expectations at the beginning of treatment in order to inform prognosis, case formulation, and treatment-planning. Regarding process expectations, clinicians may need to spend time socializing patients to the treatment process (e.g., typical role behaviors; duration), as well as checking in on patients’ met and unmet expectations as the therapy work unfolds. Regarding outcome expectations, clinicians should make a concerted effort to offer personalized hope-inspiring statements (e.g., “Your problems are exactly the type for which this therapy can be of assistance”) at the treatment’s outset, and to respond appropriately to hope-diminishing moments with both alliance-based sensitivity and expectation-enhancing strategies (e.g., reminding patients of depression’s recurrent nature; drawing on past successes) (Constantino et al., 2006).

Conclusions

The lines of research discussed above are representative of my overarching research program that focuses on understanding patient, therapist, and relational processes that influence the course and outcome of psychosocial treatments, and on the development and systematization of therapeutic interventions that address pantheoretical principles of clinical change. The overarching aim of the program is the development of empirically-grounded skills on which therapists can be trained to negotiate effective therapeutic relationships and to enhance patients’ treatment expectations. This focus on two key common factors adds a much-needed complement to the testing and training of theory-specific treatment techniques that have, to date, received much more empirical attention. Of course, the efficacy findings discussed above should be interpreted within their preliminary spirit. However, our hope is that when the jury returns, we will have uncovered two promising common factor treatment modalities that can be assimilated into CT to augment its effectiveness. If so, our work will have helped substantiate a glass-not-yet-full-but-still-full-of-promise perspective on psychotherapy outcome research.

References

Behar, E. S., & Borkovec, T. D. (2003). Psychotherapy outcome research. In J. A. Schinka & W.

F. Velicer (Eds.), Handbook of psychology: Research methods in psychology, Vol. 2. (p. 213-240). New York: John Wiley & Sons, Inc.

Bordin, E. S. (1979). The generalizability of the psychoanalytic concept of the working alliance. Psychotherapy, 16, 252-260.

Burns, D. D. (1989). The feeling good handbook. New York: William Morrow & Co.

Castonguay, L. G. (1996). Integrative cognitive therapy for depression treatment manual.  Unpublished manuscript, The Pennsylvania State University.

Castonguay, L. G., Constantino, M. J., & Holtforth, M.G. (2006). The working alliance: Where are we and where should we go? Psychotherapy, 43, 271-279.

Castonguay, L. G., Goldfried, M. R., Wiser, S., Raue, P. J., & Hayes, A. M. (1996).  Predicting outcome in cognitive therapy for depression: A comparison of unique and common factors. Journal of Consulting and Clinical Psychology, 64, 497-504.

Castonguay, L. G., Reid, J. J., Jr., Halperin, G. S., & Goldfried, M. R. (2003). Psychotherapy integration. In G. Stricker & T. A. Widiger (Eds.), Handbook of Psychology, Vol. 8 (Clinical Psychology; pp. 327-345). New York: Wiley.

Castonguay, L. G., Schut, A. J., Aikins, D., Constantino, M. J., Laurenceau, J. P., Bologh, L., & Burns, D. D. (2004). Repairing alliance ruptures in cognitive therapy: A preliminary investigation of an integrative therapy for depression. Journal of Psychotherapy Integration, 14, 4-20.

Constantino, M. J., Arnow, B. A., Blasey, C., & Agras, W. S., (2005). The association between patient characteristics and the therapeutic alliance in cognitive behavioral and interpersonal therapy for bulimia nervosa. Journal of Consulting and Clinical Psychology, 73, 203-211

Constantino, M. J., Castonguay, L. G., & Schut, A. J. (2002). The working alliance: A flagship for the “scientist-practitioner” model in psychotherapy. In G. S. Tryon (Ed.), Counseling based on process research: Applying what we know (pp. 81-131). Boston: Allyn & Bacon.

Constantino, M. J., Klein, R., Greenberg, R. P. (2006). Guidelines for Enhancing Patient Expectations: A Companion Manual to Cognitive Therapy for Depression. Unpublished manuscript.

Constantino, M. J., Manber, R., Ong, J., Kuo, T. F., Huang, J., & Arnow, B.A. (2007).

Patient expectations and the therapeutic alliance as predictors of outcome in group CBT for insomnia. Behavioral Sleep Medicine, 5, 210-228.

Constantino, M. J., Marnell, M., Haile, A. J., Kanther-Sista, S. N., Wolman, K., Zappert, L., et al. (2008). Integrative cognitive therapy for depression: A randomized pilot comparison. Manuscript submitted for publication.

De Maat, S., Dekker, J., Schoevers, R., & De Jonghe, F. (2006) Relative efficacy of psychotherapy and pharmacotherapy in the treatment of depression: A meta-analysis. Psychotherapy Research, 16, 562-572.

Frank, J. D. (1961). Persuasion and healing: A comparative study of psychotherapy. Baltimore, MD: The Johns Hopkins Press.

Grawe, K. (1997). Research-Informed psychotherapy. Psychotherapy Research, 7, 1-19.

Greenberg, R. P., Constantino, M. J., & Bruce, N. (2006). Are expectations still relevant for psychotherapy process and outcome? Clinical Psychology Review, 26, 657-678.

Hollon, S. D., DeRubeis, R. J., Shelton, R. C., Amsterdam, J. D., Salomon, R. M., O’Reardon, J.P., et al. (2005). Prevention of relapse following cognitive therapy vs medications in moderate to severe depression.  Archives of General Psychiatry, 62, 417-422.

Lambert, M. J., & Ogles, B. M. (2004). The efficacy and effectiveness of psychotherapy. In. M.J. Lambert (Ed.), Bergin and Garfield’s Handbook of Psychotherapy and Behavior Change (5^th ed., pp. 139-193). New York: Wiley.

Norcross, J. C., & Goldfried, M. R. (Eds.). (2005). Handbook of Psychotherapy Integration (2nd ed.). New York: Oxford University Press.

Roth, A., & Fonagy, P. (2005). What works for whom: A critical review of psychotherapy research (2^nd edition). London: Guilford Press.

Safran, J. D., & Muran, J. C. (2000). Negotiating the therapeutic alliance: A relational treatment guide. New York: Guilford.

Safran, J. D., & Segal, Z. V. (1990). Interpersonal process in cognitive therapy. New York: Basic Books.

Weinberger, J., & Eig, A. (1999). Expectancies: The ignored common factor in psychotherapy. In I. Kirsch (Ed.), How expectancies shape experience (pp. 357-382). Washington, DC:  American Psychological Association.

University of Massachusetts Amherst

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.

References

Ahmed, M., & Westra, H. (2007). Counselor influence on response to a treatment rationale. Paper presented at the 41st annual meeting of the Association for Cognitive and Behavioral Therapies, Philadelphia, PA.

Arnkoff, D. B., Glass, C. R., & Shapiro, S. J. (2002). Expectations and preferences. In J.C. Norcross (Ed.), Psychotherapy relationships that work: Therapists contributions and responsiveness to patients (pp. 325-346). New York: Oxford University Press.

Asch, S. E. (1946). Forming impressions of personality. Journal of Abnormal and Social Psychology, 41, 258-290.

Bleyen, K., Vertommen, H., Vander Steene, G., & Van Audenhove, C. (2001).  Psychometric properties of the psychotherapy expectancy inventory-Revised  (PEI-R). PsychotherapyResearch, 11, 69-83.

Constantino, M. J., Arnow, B. A., Blasey, C., & Agras, W. S. (2005). The association between patient characteristics and the therapeutic alliance in cognitive- behavioral and interpersonal therapy for bulimia nervosa. Journal of Consulting and ClinicalPsychology, 73, 203-211.

Constantino, M. J., Klein, R., Greenberg, R. P. (2006). Guidelines for Enhancing Patient Expectations: A Companion Manual to Cognitive Therapy for Depression. Unpublished manuscript.

Devilly, G. J., & Borkovec, T. D. (2000). Psychometric properties of the credibility/expectancy questionnaire. Journal of Behavior Therapy and             Experimental Psychology, 31, 73-86.

Dozois, D., J., A., & Westra, H. A. (2005). Development of the Anxiety Change Expectancy Scale (ACES) and validation in college, community, and clinical samples. BehaviourResearch and Therapy, 43, 1655-1672.

Frank, J. D. (1968). The influence of patients’ and therapists’ expectations on the outcome of psychotherapy. British Journal of Medical Psychology, 41, 349-356.

Greenberg, R. P., Constantino, M. J., & Bruce, N. (2006). Are expectations still relevant for psychotherapy process and outcome? Clinical Psychology Review, 26, 657-678.

Jenkins, S. J., Fuqua, D. R., & Blum, C. R. (1986). Factors related to duration of counseling in a university counseling center. Psychological Reports, 58, 467-472.

Joyce, A. S., & Piper, W. E. (1998). Expectancy, the therapeutic alliance, and treatment outcome in short-term individual psychotherapy. Journal of Psychotherapy Practice and Research, 7, 236-248.

Kirsch, I. (1990). Changing expectations: A key to effective psychotherapy. Pacific Grove, CA: Brooks/Cole.

Meyer, B., Pilkonis, P. A., Krupnick, J. L., Egan, M. K., Simmens, S. J., & Sotsky, S. M. (2002). Treatment expectancies, patient alliance, and outcome: Further analyses from the National Institute of Mental Health Treatment of Depression Collaborative Research Program. Journal of Consulting and Clinical Psychology, 70, 1051-1055.

Schneider, W., & Klauer, T. (2001). Symptom level, treatment motivation, and the effects of inpatient psychotherapy. Psychotherapy Research, 11, 153-167.

Weinberger, J., & Eig, A. (1999). Expectancies: The ignored common factor in psychotherapy. In I. Kirsch (Ed.), How expectancies shape experience (pp. 357- 382). Washington, DC: American Psychological Association.