What to Expect When Therapying – Understanding Change Process Expectations

When patients walk into the first therapeutic session, meet their therapist for the first time, and sit (perhaps comfortably, perhaps uncomfortably) on the sofa, we would say therapy has begun. But did the therapy actually begin even before this moment? With their thoughts about their therapy, their fears about how it will be, their expectations of what will happen? 

The concept of treatment expectations refers to what the patient anticipates will happen during therapy. For instance, a patient may expect a certain behavior from the therapist (role expectations), a certain length of the treatment (duration expectations) or might expect to experience something specific during therapy (process expectations; Constantino et al., 2011). Patients might also expect a specific process to take place during therapy in order for the treatment to achieve its goals (change process expectations). Surprisingly, to date, research assessing change process expectations effects is understudied. It clearly indicates a need for more research to bridge the gap between clinical work and empirical research.

Change process expectations deal with the question, when a patient enters the therapy room, what do they expect to happen that will likely result in a beneficial change? Consider this clinical encounter as an example: a teenage girl arrives for an intake meeting in the outpatient unit because she feels outcasted and depressed. During meetings with her parents, they repeatedly stated their expectation that the therapist will provide them with practical tools to help their daughter. However, the therapist saw the importance of creating a relationship and building trust as the most crucial part of therapy. These gaps could have been bridged, but after a few meetings they decided to end the therapy, maybe due to the therapist’s lack of ability to meet their expectations. 

In another clinical encounter, a patient with emotionally unstable relations, dependent behaviors, and an ongoing eating disorder expresses her desire to engage in therapy in order to “have a place to share her experience without judgment of friends or my parents.” After a few months it was apparent that she has made some progress in therapy and even expressed satisfaction, but what has the therapist done that met her expectations? Did she indeed feel that she had a place to share her experiences without judgment? What processes made her feel that she was moving in the right direction and which processes made her feel that something was off?

To allow an in-depth investigation of these processes, a self-report tool, named the Expectations of Active Processes in Psychotherapy Scale (EAPPS), was recently developed to tap into potential therapeutic change processes. The items in the EAPPS were derived from measures of change mechanisms previously described in the literature, such as the working alliance (Horvath & Greenberg, 1989), transference interpretations (Bøgwald et al., 1999), and measures of active participation (O’Malley et al., 1983). It asks to rate different sentences which describe potential processes of change, such as “Learn from emotions”, “Understand therapist’s feelings towards me”, “Cope with stresses” etc. The factor analysis, which was performed to identify the most common factors, found seven ingredients: establishment of positive therapist-patient relations, verbal processing of therapist-patient relations, exploration of unexpressed contents, the ability to share sensitive contents openly and secretly, working through specific emotional problems, therapy fosters resilience, and therapy provides tools for cognitive control (Tzur Bitan et al., 2018).

How can these factors be interpreted and transformed into real-life clinical experiences? Well, it is apparent that the parents of the teenager who was struggling with feelings of alienation expected therapy to include the provision of specific tools, such as helping their daughter reconstruct her automatic thoughts, or view reality in a slightly more positive way. On the other hand, the therapist may have believed it would be more beneficial to form a therapeutic bond, listen to unconscious contents, or explore transference processes through her projected emotions. Clearly, the parents and the therapist had significant gaps in what they expected to be beneficial at this stage of therapy. Indeed, gaps in change process expectations are common in psychotherapy. For example, in a dyadic study exploring patients and their therapists during the first three months of therapy, patients and their own therapists differed in what they perceived as the therapeutic change process. As therapy was initiated, patients expected therapy to focus on providing cognitive tools, whereas their therapists perceive the mechanism of change to be the verbal processing patient-therapist relationship. Surprisingly, three months into therapy, change process expectations did not change, and patients and their therapists continued to show the same gaps regarding the expected therapeutic process (Tzur Bitan et al., 2021).

What are the implications of such gaps between patients and therapists? Patients entering therapy for the first time in their life, expecting to receive tools to handle stress, might be very surprised if the therapist will inquire about their emotions towards them. Patients can feel embarrassed, surprised, or even intruded upon. They might think – “Why do I need to speak about my feelings towards the therapist? How will it help me?” Therapists, in turn, may feel that their interventions are inadequate or may even try to find ways to repair the therapeutic bond or make more sense of their intervention. Especially in the first stages of therapy, these gaps can influence a patient’s willingness to stay in therapy, and in some cases, even lead to patients dropout, as demonstrated in the clinical example above. 

Having said that, gaps are not always detrimental to the therapeutic process and outcome. For example, studies demonstrate that when a therapist rates the bond with the patient lower than the patient, the therapy process can be more successful (Marmarosh & Kivlighan Jr., 2012). This phenomenon, previously explained as a ‘better safe than sorry’ effect, suggests that the therapist takes a safer approach in  perceiving the therapeutic bond to maintain vigilance and alertness towards changes in the alliance (Atzil-Slonim et al., 2015). In this context, one might ask: what are the effects in gaps in change process expectations? are these gaps beneficial or harmful to the therapeutic process and outcome?

In a recent study, patients and therapists rated their change process expectations at baseline, while patients rated their psychological distress at baseline and three months into therapy. The results revealed different effects of change process expectations and distress level. For example, patients’ expectation that therapy will focus on sharing sensitive contents openly and securely was related to an improvement in patients’ distress, whereas the expectation that therapy will focus on the exploration of unexpressed contents showed the opposite effect. Moreover, improvement was reported when patients rated the sharing of sensitive contents openly and securely higher than their therapists (Brugnera et al., 2024). These findings suggest, somewhat like in alliance congruence, that gaps in therapy perceptions are not always associated with negative outcomes.

Another interesting question related to change process expectations is how they are formed. One potential way to form expectations about the therapeutic change process is through the media and how therapy is portrayed in movies and TV series (Orchowski et al., 2006). For example, some cinema portrayals in Eastern countries may include blurred patient-therapist boundaries or overemphasis on therapist self-disclosure (Menon, 2024), which might lead to patients’ expectations to such change processes. Expectations about therapy can also be created or influenced by an individual’s own experience as a patient. For example, people might learn about the therapeutic change through the interventions of therapists. Alternatively, expectations can be co-generated by both the patient and the therapist. According to such possibility, therapists may come with preconceived notions about the mechanism of change but may revise and revert to other mechanisms as they learn about the patient’s thoughts and wishes. Similarly, patients might not learn what therapy is about, but rather create their own expectations about therapy with the therapist. In other words, change process expectations may be dynamic and evolve as the therapeutic endeavor progresses, with both patients and therapists constantly modulating and changing their views of the right process at each stage of the therapy. These intriguing sources remain to be investigated in future research.

It is also important to understand the cultural influences affecting therapy process expectations of both the patient and the therapist. Western cultures tend to emphasize individualism and self-exploration, which might lead to the expectation to discuss and work on the patient’s goals and wishes. The therapist might also expect a collaborative process of working mutually on these goals with certain responsibility being taken by the patient. However, many Eastern cultures tend to place more focus on collectivism. In such cultures, patients may look up to the therapist as a guide (Ma, 2000) or as a savior, who will direct their life decisions and tell them what to do (Reddy, 1988). Furthermore, patient expectations might include the anticipation that therapy will incorporate their roles and responsibilities towards their family and community. In such cases, the patient may expect the therapist to think collectively and not just about themselves. Therapist expectations might also differ in such cultural contexts, either through their identification with cultural norms, or alternatively through their attunement with the patient’s perspectives.

Beyond the Western/Eastern cleavage that influences therapy expectations, there are numerous factors, such as societal norms, cultural beliefs, prevailing attitudes, and the stigma associated with seeking psychotherapy that vary depending on the predominant theoretical approach. For instance, in cities like New York, Paris, or Buenos Aires, the psychoanalytic approach not only predominates but is also intertwined with intellectual pursuits that are highly regarded rather than stigmatized. These cultural contexts not only shape how therapy is perceived and sought but also influence the expectations patients and therapists bring to the therapeutic process. In such cities, for example, it might be more expected that patients and therapists will perceive the therapy as exploration of unconscious contents, rather than other mechanisms of change.

Clearly, there is much to be learned about how individuals perceive the therapeutic process, and how it affects their expectations. The studies performed thus far suggest that patients’ and therapists’ change process expectations have clinical relevance and are likely to inform the therapeutic process. In our view, therapists should be aware of patient’s perceptions of the therapeutic process, what they expect will transpire during therapy, what process would be attuned to their expectations and what processes will not. Furthermore, therapists might need to be aware of cultural and social influences such as cinema-based stereotypical prototypes, discuss their influence within therapy, and aim to provide accurate information to their patients (Orchowski et al., 2006). Recognizing and respecting these cultural variations can enhance therapeutic rapport and outcomes, ensuring that treatment is both respectful and relevant to the patient’s cultural context. Many questions remain to be addressed by a scientific exploration, including whether therapists’ expectations change from patient to patient; if therapists match their perceptions to their patient’s views as time progresses; how therapists’ change process expectations affect therapy outcomes, and many more. These questions may inform future clinical practice and may facilitate the improvement of psychotherapy for the benefit of our patients.