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How your expectations of therapy can influence the outcome.

Academic debates about the efficacy of psychotherapy have been going on for decades. Most research and therapists agree that trust between client and therapist and the degree to which a therapist can empathically hold a space for a client is the foundation upon which any positive therapeutic change is built. While this is important, it is by no means the only variable. Interestingly, no one can definitively agree on the elements that lead to positive change, but while the debate rages on, the one thing everyone does agree on is that psychotherapy, in and of itself, undoubtedly works.

The number of variables in any given therapeutic setting are too many to count, from the education, skill and experience of the therapist, to the personalities and preferences of both client and therapist and the specific tools within the approach that are used. However, let’s not forget that you, the client, are not a passive participant. Clients have an indispensable part to play in their own therapeutic journeys. Some elements of this role are conscious and easy to recognise, while others are a bit more hidden. The element I want to explore in this article is arguably mostly hidden; expectation.

The research on how much a person’s expectation of therapy can influence its outcomes has been ongoing for decades and yet it is considered one of the most underrated and under researched predictors of therapeutic outcomes. Expectation in this context can be broken down into three things; role expectation, process expectation and outcome expectation.

Role Expectation Each person in the therapeutic relationship, client or therapist has a role to play. In simple terms you could describe the client as having a talking role and the therapist a listening role. However, it is more nuanced than this especially when you think about therapeutic modalities that don’t rely as heavily on talking and listening. Our expectations of our role in therapy will depend on our personalities, preferences, and past experiences of therapy and of therapists, for example. Everyone walks into therapy, knowingly or not, with some expectation of their role. The trouble is that this role is not well defined in our heads because of all these variables, and if the therapist doesn’t address this early on in the relationship, it can be a confusing thing to navigate on our own. If your therapist doesn’t address this in an assessment or initial consult session, I encourage you to ask them to. It can be as simple as saying:

“I’m not sure what’s expected of me during sessions, could you help me with that?”

For example, most therapist will encourage clients to lead the sessions in terms of deciding what it is they feel they want to explore in any given session. However, it is my experience that many clients prefer the therapist to lead as they aren’t sure what might be best to do; something new, something recent, or continue with something difficult from last time. Even if your therapist agrees that their role can be to lead the sessions, they will hopefully work toward exploring, with you, how it feels to slowly take the reins of each session; to learn what you feel you might need, and what you feel you need to explore each week. In this way, the role of ‘leader’ may then shift subtly, bringing with it a sense of your own empowerment.

In whatever way it plays out for you, it’s important to be explicit about your role expectations so that you aren’t left guessing.

Process Expectations Process expectation is really important in, for example, the context of Somatic Experiencing (SE) because it is a lesser known approach, often conflated with previous experiences of other therapies. With books, movies and TV giving us an inside look as to what we might expect a talking therapy session to look like, SE, with its inclusion of physiological responses to traumatic events, can be both daunting and unsettling for those who may not know what to expect. The same can be true of other modalities like EMDR or internal family systems (working with parts). An assessment or initial consult helps enormously to express and manage expectations because it allows you, the client, to ask any questions you have about how the therapy session proceed, and it gives the therapist an opportunity to explain or even give you a mini session to help you to decide if this way of working is something that you can imagine yourself doing. An example of getting the ball rolling on this would be:

“I have no idea what happens in a session, can you give me an example of what a session might look like?”

No one can expect to know exactly what will happen in each session as there needs to be a sense of fluidity to how any session goes, but you can certainly get a good idea of how the therapist works. Having a clearer sense of your expectations meeting the reality of your sessions will help in achieving the next bit…your expectation of the outcomes.

Outcome Expectations It would be easy to assume that everyone that attends therapy has an expectation of a positive outcome, but this is not the case. Many people come to therapy feeling like it’s something they should be doing but have no real expectation of anything changing. Studies show that those who have an expectation of positive outcomes in therapy are more likely to experience them. In fact, expectation accounts for 15% of all the variables in positive therapeutic outcomes which is an enormous number when one considers how many variables there are in any given situation where two strangers come together to achieve an often-unspecific goal. This is not surprising, though. Anecdotally, I wish I had a penny for every client that told me that once they knew they were starting therapy, they started to feel better. In these cases, they have an expectation of support and relief, certainly, but also an expectation of change, which gives them hope and kickstarts a physiological and mental transformation that is further supported by weekly therapy. This is not to say that all you have to do is close your eyes and believe for the best, though decades of research wouldn’t discount how important that is as an element of change. You also don’t have to feel full of hope and be buzzing about attending therapy. It’s understandable that sometimes you just can’t see past getting through the day. However, if you can allow someone to help you to see a glimmer through the trees. Something that tells you that you’re on the right path and that perhaps there is something coming up the road that will bring hope, empowerment and peace, then that glimmer will grow. Be as open and honest with your therapist or potential therapist about your expectations and allow space for those expectations to be challenged or encouraged. No therapist is going to want to promise you the world. It would be disingenuous at best and dangerous at worst. However, offering you a realistic assessment of what is possible may help to manage your expectations up or down. Again, if we can begin to match our expectations to the realities of the therapy, the chances of success will increase.

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