Expectations about Therapy

Client expectations about counseling and psychotherapy are widely believed to influence the therapy process and outcome. Theorists from disparate theoretical persuasions have included expectations as a central construct in their theories. Research on the common factors that account for much of the success of psychotherapy confirms the influence of client expectations.

The Construct of Expectations

Development of Construct of Expectations

Oswald Kulpe and Edward B. Titchener formulated the concept of an expectation as a cognitively mediated preparatory set or disposition to behave in a particular manner in a given situation. Narziss Ach named this disposition a “determining tendency,” thereby emphasizing the effects of expectations on perception and behavior. By definition, therefore, expectations influence perceptual and judgmental processes, learning, and behavior.

Jerome Bruner, Leo J. Postman, and Harry Helson elaborated the role of expectations in influencing behavior. Bruner and Postman theorized that the process of perception begins with an expectation or hypothesis. Helson viewed expectations as critical determinants of people’s “adaptation level” (i.e., the cognitive norms people use in interpreting sensory information). Learning theorists such as Edward C. Tolman (cognitive theory), Clark L. Hull and Kenneth Spence (drive reduction theory), and Julian B. Rotter (social learning theory) viewed learning as a function of the reinforcement of one’s expectancies regarding the outcome of behavior in a given situation.

Social psychologists incorporated expectancies as a central construct in explaining social cognition. Cognitive expectancies (i.e., preparatory sets) are viewed as primary determinants of behavior in George A. Kelly’s personal construct theory, Kurt Lewin’s aspiration theory, Leon Festinger’s cognitive dissonance theory, and Theodore Newcomb’s attraction theory.

Expectations in Counseling and Psychotherapy

Theorists also viewed expectations as central to the success of psychotherapy. Clients’ expectations influence their decision to enter into and remain in therapy and they moderate the effectiveness of therapy. Clients approach therapy with expectancies regarding the nature of therapy and the roles they and their counselors will assume. Counselors’ and clients’ expectations are important determinants of their behavior in counseling.

Arnold P. Goldstein distinguished between prognostic expectations (e.g., beliefs concerning the probability of success in counseling) and participant role expectations (i.e., beliefs regarding the behaviors that will be displayed by the client and counselor). Bernard Apfelbaum suggested that clients expect one of three basic types of counselors. The critic is a cold, rigid, judgmental therapist who gives advice, but is not concerned with whether the client uses it. The model is a tolerant, accepting, permissive therapist. The nurturant therapist is giving, guiding, and protective. Expectations such as these influence people’s choice of a help giver, their perceptions of their therapists, the quality of the communication process, their persistence in counseling, and the effectiveness of counseling. Most of these theoretical assertions have been supported by empirical research.

Early Research on Expectations about Therapy

Most research on expectations about counseling prior to the early 1970s focused on the placebo effect of expectancies and expectations regarding the therapists’ behavior.

Placebo Effect of Expectancies

The placebo effect was named after the practice in medical research of prescribing a benign treatment (e.g., a “sugar pill”) to a control group of patients. This allows researchers to determine whether spontaneous, non-treatment-related improvements occurred during the study. It is possible that the mere act of entering therapeutic treatment could stimulate improvement. Some psychologists theorized that all of the gain from therapy was the result of a placebo effect.

Research through the early 1970s investigated whether the gains observed in therapy were attributable to the mere expectation that therapy would be effective. Several early studies supported that theory. Wallace Wilkin’s critical analysis in 1973, however, demonstrated that those studies supporting the placebo effect theory had not used suitable experimental controls. Studies in which effective experimental controls were used did not support the placebo effect.

Psychologists now understand that the creation of an expectation to benefit from therapy is one of the common factors associated with a positive therapeutic outcome. All approaches to psychotherapy strive to create hope and a more positive outlook on life by stimulating an expectancy to benefit from therapy. While advocates of the placebo hypothesis thought that expectancy effects accounted for all of the gain from therapy, psychologists now estimate that 15% of the gain from therapy is due to expectancy effects.

Therapist Behavior

Another line of research investigated the types of behaviors students expected from counselors. In general, students expected their counselors to maintain confidentiality and to be thoroughly prepared for the interview, at ease with them, and skilled at dealing with their problems. Consistent gender differences in expectancies were observed. Males expected a more directive, critical, and analytical counselor; females expected a more nonjudgmental, permissive listener. However, both men and women preferred that the therapist offer advice.

Measuring Expectations about Therapy

Prior to the 1980s, investigators constructed their own questionnaires to measure expectations about counseling. This resulted in numerous problems. Each study focused on a single or very limited range of expectancies and often a single item was used to measure expectancies. The single-item and multiple-item scales that were used lacked reliability and validity. Many of the instruments did not distinguish clearly and accurately between expectations, preferences, and perceptions, and many instruments defined expectations inaccurately. Systematic programs of research were lacking. These practices yielded idiosyncratic findings and interfered with the development of a coherent understanding of expectancy effects.

Expectations, Preferences, and Perceptions

Distinguishing among expectations, preferences, and perceptions is critically important because research reveals differences among them. Expectations are subjectively held probability statements that represent the person’s estimate of the likelihood that an event will occur (e.g., the counselor will understand my problem) or a condition will exist (e.g., the therapist will seem trustworthy). Expectations refer to the future, and they can exist in the absence of direct experience with the event or condition. Some investigators have used anticipations as a synonym for expectations, but that term is most commonly used in studies of serial anticipation learning. Expectations is the term that is more commonly used throughout psychology, and particularly in studies examining issues pertaining to counseling and psychotherapy.

Preferences refer to the strength of the person’s desire that an event will occur or a condition will exist. Preferences can be stated in the absence of direct experience with the event or condition. Some investigators have used hope as a synonym for preference, but hope (i.e., to look forward with desire and reasonable confidence) involves both expectations and preferences. Knowledgeable psychologists avoid the use of hope in studies of expectations and preferences.

Perceptions refer to the person’s comprehension, understanding, or knowledge of an event or the existence of a condition gained by means of direct observation. A perception is a subjective statement of fact. Perceptions refer to events or conditions that occurred in the past or that are ongoing at the present. Perceptions require direct experience with the event or condition.

Expectations about Counseling—Brief Form

The development of the Expectations About Counseling—Brief Form (EAC-B) was an important landmark in psychologists’ efforts to investigate the influence of expectations on the counseling process and outcome. The development of a reliable and valid measure of expectations and the clarification of the constructs of expectations, preferences, and perceptions helped to advance the methodological rigor of research on expectations about counseling.

The EAC-B is a 66-item instrument that measures 17 specific expectations and 3 broader expectations factors. The 17 expectations are grouped into five clusters, expectations about: client attitudes and behaviors (Responsibility, Openness, and Motivation), counselor attitudes and behaviors (Acceptance, Confrontation, Genuineness, Directiveness, Empathy, Self-Disclosure, and Nurturance), counselor characteristics (Attractiveness, Expertise, Trustworthiness, and Tolerance), characteristics of the therapy process (Immediacy and Concreteness), and quality of outcome (Outcome). The three factors measured by the EAC-B are the expectation to make a Personal Commitment, the expectation that the Facilitative Conditions will be present during therapy, and the expectation of Counselor Expertise. Analysis of counseling research in the 1990s revealed that the EAC-B was the sixth most commonly used instrument in published counseling psychology research. The instrument has been translated into Chinese, Dutch, French, Icelandic, Polish, and Spanish and used around the world.

Reliability and Validity of EAC-B

Numerous studies have documented the internal consistency, test-retest, and parallel forms reliability of the EAC-B and its validity using varied criteria. The factorial validity of the EAC-B has been demonstrated across variations in culture, language, and client or nonclient status. The three-factor structure has emerged from analyses using all of the major variations of the components analysis and factor analysis procedures. The evidence demonstrates unequivocally that the factor structure of the EAC-B is not an artifact of the item format, and that the EAC-B measures constructs that are distinctly independent of related constructs such as career concerns, counseling readiness, ego strength, level of psychosocial development, perceived psychological difficulty, perceptions of counseling, perceptions of counselors, and personality.

Much of the research on expectations has been performed on college and university campuses using typical students. Psychologists have questioned the generalizability of research on students to clients seeking services in university or nonuniversity settings. There is encouraging evidence that the results obtained with nonclient students are generalizable to student and adult clients. Studies comparing students (not in counseling) to student and nonstudent clients indicated that the expectations of the students did not differ from those of either of the client groups, and that the internal structure of the EAC-B was the same for students and adults who were seeking counseling.

Importance of Expectations

The likelihood of mental illness is higher in the 15- to 24-year-old age range than in other age ranges, and suicide is the third leading cause of death in that age range. Nevertheless, a national study by Darrel A. Regier and his associates of more than 20,000 individuals revealed that only 28.5% of those who met the criteria for a mental or addictive disorder received any treatment during that year. Many psychologists believe that negative opinions about mental illness and expectations about psychotherapy are responsible for the underuse of mental health services.

Prevalence of Unrealistic Expectations

A national survey of practicing therapists conducted in 1993 by Howard E. A. Tinsley revealed that a significant proportion of their clients have unrealistic expectations about counseling. The percentage of therapists reporting that “some, many, or most” of their clients have unrealistically low expectations ranged from 7% for the expectation of counselor expertise to a high of 81% for the expectation to assume responsibility for the success of therapy. The percentage of therapists reporting that “some, many, or most” of their clients have unrealistically high expectations ranged from 19% for the expectation of client openness to a high of 88% for the expectation of counselor directiveness. Adding the percentage of clients that have unrealistically low and high expectations (e.g., 67% + 19% = 86% for client openness) reveals that a sizable majority of clients have unrealistic expectations of counseling. In general, clients tend to underestimate the work they will have to do in counseling and to overestimate the skill of the counselor, a phenomenon that has been described as “magical thinking.”

Consequences of Unrealistic Expectations

The national survey conducted by Howard E. A. Tinsley and associates revealed that from 36% to 100% of therapists view unrealistically low expectations as detrimental to the counseling process, depending on the specific expectation. Unrealistically high expectations about counseling are viewed as detrimental by 38% to 93% of therapists. Thus, experienced therapists report that a majority of their clients have unrealistic expectations about counseling and that those expectations are detrimental to the therapeutic process.

Expectancy Manipulation

One of the early goals in therapy is to help the client form more realistic expectations about the therapy process, but therapists describe that as difficult to accomplish. The percentage of therapists who view the modification of unrealistic expectations as moderately difficult ranges from a low of 59% for Facilitative Conditions to a high of 66% for Personal Commitment and Counselor Expertise. Therapists most frequently report that three aspects of Personal Commitment (Attractiveness, Outcome, and Responsibility) and two of the Facilitative Conditions (Nurturance and Trustworthiness) are very difficult to modify.

Overview of Expectancy Manipulation Research

Close to 50 studies have investigated the effectiveness of alternative approaches to modifying expectancies. The individuals studied in this research have included children, counseling center clients, college students, church group members, community mental health center clients, psychiatric outpatients, schizophrenic patients, rehabilitation center clients, and veterans receiving vocational counseling. Investigators have attempted to modify expectancies for the facilitative conditions (e.g., counselor expertness, attractiveness, and trustworthiness), prognosis for therapy, therapist techniques, therapist theoretical orientation, client behaviors and role expectations, and general counseling process and procedures.

In aggregate, these studies investigated six types of interventions. Audiotaped expectancy manipulations generally present research participants with an introduction to therapy in the form of direct instruction or examples of effective and ineffective interviews. Videotaped or motion picture interventions typically provide didactic information for role induction purposes. Verbal instructions usually involve telling participants face-to-face about the nature of therapy, appropriate in-session behavior, and prognostic expectancies. Printed materials typically provide information about the expectancies the investigator is attempting to change. Use of the counseling interview to modify expectancies typically involves administration of an expectancy measure, conducting an intake or initial interview, and then readministering the same expectancy measure. The single study in which a complex intervention was used involved a preparatory psychotherapy class in which written and verbal materials, a film, a group discussion and role-playing exercises were used.

Methodological weaknesses are widespread in this research because investigators violated basic principles of experimental design. They failed to randomly assign participants to the experimental conditions, so any differences observed after the experimental intervention may be due to initial differences among the groups. Many used a pretest-posttest design in which participants’ expectations were measured prior to the manipulation. This alerts participants to the issues under investigation. For example, asking participants whether they expect a therapist to use confrontation sensitizes them to this issue. Furthermore, most of the investigations focused on a single or narrow range of expectancies. Typically, the measures used in this research consisted of single items, lacked demonstrated reliability and validity, used invalid definition of expectations, and confused expectations, preferences, and perceptions. The investigators often failed to evaluate the long-term effects of the expectancy manipulations, to relate expectancy manipulation to any important aspect of the therapeutic process or outcome, or to perform a manipulation check (i.e., to determine whether the manipulation had the desired effect). Finally, when multiple manipulations were performed, they failed to examine the possibility of interactions among the manipulation procedures.

Effectiveness of Modification Strategies

Despite these flaws, three conclusions can be drawn from the literature. First, the use of complicated experimental interventions is unnecessary and unsuccessful. Audiotaped and videotaped interventions are most likely to be successful. Printed materials typically have been ineffective and the effectiveness of verbal interventions is doubtful. Second, there is no evidence that actual experience in counseling is an effective method of changing expectations; the studies that examined this approach were of quite poor quality. This procedure is more costly than a direct experimental intervention and it is unlikely to be more effective. Third, the conditions under which the expectancy manipulation strategies are effective are unclear because each type of intervention frequently failed to produce significant results.

There are theoretical and empirical reasons for viewing expectancies as important to the success of counseling, there is unambiguous evidence that unrealistic expectancies are common and detrimental to the counseling process and outcome, and therapists report that changing expectations is difficult. These suggest that a concerted focus on the efficacy of expectancy manipulation strategies deserves a high priority from psychologists.

Correlates of Expectations

Culture

Expectations are learned and modified through interactions with the environment. This suggests that the social and cultural milieu in which people develop influences their expectations about counseling. However, three caveats suggest caution when interpreting the research on cross-cultural differences in expectations. First, most theories of counseling and psychotherapy reflect the North American and Western European (i.e., Euro-American) cultural perspectives. These theories define the desirable roles and behaviors of the therapist and client, and consequently the interpretation of research comparing the expectations of persons from different cultural heritages. Second, the rate of cross-cultural interaction is increasing exponentially. The cultural heritage of each generation is different from that of the preceding generation, so research findings obtained only a couple of decades ago may already be dated. Finally, while this issue has enjoyed some research attention, the body of evidence is so sparse that only a very tentative summary can be offered.

In general, Euro-Americans are more skeptical than others about the expertise of the counselor and the likelihood that facilitative conditions will be salient during therapy. They are more pessimistic that the counselor will be able to help them determine what is the matter with them, help them identify particular aspects of their behavior that are relevant to their problems, or help them solve their problems. They have lower expectations that the counselor will explain what is wrong and offer useful suggestions and advice. They think it is less likely that the counselor will understand and help them to better understand and explain their feelings. They also regarded it as less likely that the counselor will give them support, encouragement and reassurance, or praise them when they show improvement.

Individuals raised in Middle Eastern, Islamic, and African cultures are somewhat similar to each other in their expectations of counseling, and more similar to Euro-Americans and individuals raised in a Spanish culture than to Asians. When compared to persons raised in a Euro-American culture, they generally have stronger expectations regarding the likelihood of counselor expertise and facilitative counselor attitudes, behaviors, and techniques such as immediacy and concreteness. In other respects, their expectations differ little from those of Euro-Americans. Too high an expectation of counselor expertise may represent a form of magical thinking, but the skepticism underlying low expectations for counselor expertise is not a healthy prognostic sign either. Counselors working with clients exhibiting either type of unrealistic expectation typically report that they need to help the client gain a more realistic expectation before progress in counseling is likely.

Asian individuals expect the counselor to remain more disengaged than persons from other cultures. They report stronger expectations that the counselor will be courteous, respect their privacy, and keep their relationship distant and smooth. In general, they expect to be more guarded in revealing important information to the counselor. They expect the counseling process to be less focused on their feelings and problematic behaviors, and they expect to be less personally revealing about those issues. Perhaps as a reflection of this expectation regarding personal revelation, they also have lower expectations that the counselor will genuinely reveal him- or herself.

Asian individuals expect to take less personal responsibility for making decisions, for talking about their concerns during counseling, and for working on their problems outside of counseling. They also have lower expectations to work during the counseling sessions on new behaviors and ways of solving problems. Relatively speaking, they expect the counselor to be less likely to focus on inconsistencies between their feelings and behaviors and between their goals and present behavior, and they are more pessimistic about gaining a better understanding of themselves and improving their relationships with others. Counselors who are not aware of multicultural differences may view the behavior of their Asian clients as indicating an unwillingness to work hard and make a serious commitment to therapy.

Persons from Hispanic cultures have a stronger expectation to take personal responsibility for the success of therapy than Asians (and in some respects stronger than all other groups). They have a stronger expectation to persist in counseling despite the occurrence of painful and unpleasant times. They expect to work on their concerns outside of counseling and to practice new behaviors and new ways of solving their problems during the counseling interviews. They have stronger expectations to take personal responsibility for making decisions during therapy, for gaining a better understanding of themselves and others, and for improving their relationships with others. They report stronger expectancies to openly discuss their emotions and problems during counseling and to work with the counselor to better understand their feelings and discover aspects of their behavior that contribute to their problems. They expect to face up to inconsistencies in their thoughts and actions and inconsistencies between their goals and behaviors.

Developmental Level

Erik Erikson theorized that life-span development progresses through a series of psychosocial stages characterized by developmental tasks. Completion of these tasks provides the individual with new methods of coping with the environment, new ways of viewing the world, and advancement to the next stage.

Expectations about counseling vary as a function of the development of mature educational plans, career plans, and lifestyle plans. The development of mature educational plans is associated with uniformly more positive expectations about counseling. The development of mature career and lifestyle plans is associated with a more varied pattern of change in expectations. Psychologists modify their counseling styles to communicate effectively with persons at different levels of psychosocial development.

Individuals’ expectations about their own attitudes and behaviors during counseling are unrelated to their level of psychosocial development. However, their expectations of the counselor, the counseling process, and the outcome of therapy become more positive as they gain in psychosocial maturity. For example, expectations about the facilitative conditions become more favorable as psychosocial maturity increases. Developmentally less mature students are more skeptical that these conditions will exist, and they may be less likely to perceive the level of facilitative conditions that exist within the actual counseling relationship. Developmentally less mature students are also less likely to understand the necessity of working hard in counseling and of taking responsibility for the success of counseling. One early goal of therapists working with less developmentally mature students is to help them develop a sense of personal responsibility for the success of counseling.

Research Directions

This entry highlighted numerous weaknesses in the research on expectations about counseling, including the frequent use of instruments having no demonstrated reliability or validity and the lack of programmatic research. This entry also identified areas needing research attention. Perhaps the most significant oversight, however, is the lack of research on the effects of expectations about counseling on the counseling process, counseling outcome, and premature termination.

It is reasonable to think that clients’ expectations will have an important effect on their behavior during therapy, at least during the first few sessions. The quality of the counseling relationship is critical to the success of counseling, regardless of the theoretical orientation and specific approach of the psychologist. Despite this, investigations of the counseling process have largely ignored client expectations.

One investigation of the relation of client’s expectations to their level of involvement during career counseling hints of the importance of this issue. Clients having relatively high expectations of personal commitment and facilitative conditions were paired with clients having relatively low expectations on those factors. Both clients in a pair received services from the same therapist, and audiotapes of the first interview were rated to obtain measures of the client’s level of involvement in therapy.

The clients with more positive expectations participated at a higher level of involvement during the initial interview. They were more willing to talk about themselves rather than people in general, more likely to become emotionally involved, and more likely to report personal reactions and to describe their feelings. In contrast, the clients who had relatively negative expectations of counseling talked about external events and limited themselves to descriptions of behaviors and intellectualized self-descriptions. They never departed from this guardedness during the initial interview.

These findings only hint at the importance of this line of research. Numerous studies have found that a high level of involvement is positively related to counseling outcome. Research that examines the relation of expectations to aspects of the counseling process and outcome has great potential to significantly advance knowledge of the therapy process.

References:

  1. Gonzalez, J. M., Tinsley, H. E. A., & Krueder, K. R. (2002). Effects of psychosocial interventions on opinions of mental illness, attitudes toward help seeking, and expectations about psychotherapy in college students. Journal of College Student Development, 43, 51-63.
  2. Hayes, T. J., & Tinsley, H. E. A. (1989). Identification of the latent dimensions underlying instruments measuring perceptions of and expectations about counseling. Journal of Counseling Psychology, 36, 492-500.
  3. Kunkel, M. A., Hector, M. A., Coronado, E. G., & Vales, V. C. (1989). Expectations about counseling in Yucatan, Mexico: Toward a “Mexican psychology.” Journal of Counseling Psychology, 36, 322-330.
  4. Reiger, D. A., Narrow, W. E., Rae, D. S., Manderscheid, R. W., Locke, B. Z., & Goodwin, F. K. (1993). The de facto U.S. mental and addictive disorders service system: Epidemiologic catchment area prospective one-year prevalence rates of disorders and services. Archives of General Psychiatry, 50(2), 85-94.
  5. Tinsley, D. J., Hinson, J. A., Holt, M. S., & Tinsley, H. E. A. (1990). Level of psychosocial development, perceived level of psychological difficulty, counseling readiness, and expectations about counseling: Examination of group differences. Journal of Counseling Psychology, 37, 143-148.
  6. Tinsley, H. E. A. (1980). Expectations About Counseling— Brief form. Mukilteo, WA: Author.
  7. Tinsley, H. E. A. (1980). Manual for the Expectations About Counseling. Mukilteo, WA: Author.
  8. Tinsley, H. E. A., Barich, A. W., & Bowman, S. L. (1994). Unrealistic expectations about counseling and psychotherapy: Counseling psychologists’ perceptions of their effects and modification. Guidance and Counselling, 9, 20-24.
  9. Tinsley, H. E. A., Bowman, S. L., & Barich, A. W. (1993). Counseling psychologists’ perceptions of the occurrence and effects of unrealistic expectations about counseling and psychotherapy among their clients. Journal of Counseling Psychology, 40, 46-52.
  10. Tinsley, H. E. A., Bowman, S. L., & Ray, S. B. (1988). Manipulation of expectancies about counseling and psychotherapy: A review and analysis of expectancy manipulation strategies and results. Journal of Counseling Psychology, 35, 99-108.
  11. Tinsley, H. E. A., Tokar, D. M., & Helwig, S. E. (1994). Client expectations about counseling and involvement during career counseling. Career Development Quarterly, 42, 326-336.
  12. Tinsley, H. E. A., & Westcot, A. M. (1990). Analysis of the cognitions stimulated by the items on the Expectations About Counseling—Brief Form: An analysis of construct validity. Journal of Counseling Psychology, 37, 223-226.
  13. Wampold, B. E. (2001). The great psychotherapy debate: Models, methods, and findings. Hillsdale, NJ: Lawrence Erlbaum.

See also: