What clients think CBT will be like and how it really is

Some people expect cognitive behavioural therapy (CBT) to be more prescriptive than it is, and therapists to be more controlling than they really are. That's according to a series of interviews with 18 clients who undertook 8 sessions (14 hours) of CBT to help with their diagnosis of generalised anxiety disorder.

Henny Westra and colleagues selected for interview nine clients whose therapy had ended positively and nine whose therapy had ended poorly. Four of the clients were male. There were four CBT therapists - two men and two women. One was PhD qualified, two were senior clinical psychology grad students, one was junior.

The vast majority of client comments (84 per cent) relating to expectations were that the CBT was not what they'd anticipated. Clients whose outcome was good tended to say they'd been pleasantly surprised - the therapist was collaborative and non-judgmental, and they'd had the opportunity to direct the therapy and choose what to talk about. Of the therapeutic process, the positive outcome clients felt, to their surprise, that they could trust the process, felt comfortable, and that they learned more than they expected. Both good and poor outcome clients worked harder in therapy than they anticipated.

Unsurprisingly, the poor outcome clients tended to say they'd been disappointed by the therapeutic process. In the majority of cases, they took pains not to blame their therapist, instead attributing their lack of progress to time constraints, poor health, their own unrealistic expectations, or their failure to remember the techniques. Direct criticism of the therapist was rare (even though interviewees were reassured their comments were confidential). One person said it would have been better not to have waited until session seven to discuss a key subject from their past.

Sixteen per cent of expectation-related comments conveyed that therapy was just as had been expected. One good outcome client in this category said they thought the therapist would get to the root of their problems, and he did. Poor outcome clients, by contrast, tended to make superficial remarks: 'it was fairly similar to what I expected, I guess'.

The broader context for this research is that client expectations are one of several factors that are known to be associated with therapeutic success (with positive expectations tending to precede good outcomes). However, very little research until now has looked at expectancy violations - that is, when therapy isn't what was expected, for good or bad.

'The findings ... suggest that expectancy disconfirmation in CBT, particularly negative expectations for the therapist and the therapy process, is a common and potentially powerful phenomenon in the experiences of CBT clients with good outcomes,' the researchers said.

A major shortcoming of this research is that the interviews weren't conducted until after the final therapy session, so it's possible that clients recalled their earlier expectations in light of their positive or negative experiences in therapy.
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Westra, H., Aviram, A., Barnes, M., & Angus, L. (2010). Therapy was not what I expected: A preliminary qualitative analysis of concordance between client expectations and experience of cognitive-behavioural therapy. Psychotherapy Research, 20 (4), 436-446 DOI: 10.1080/10503301003657395