What Works in Therapy  |  Douglas Behan, DSW, LCSW

Hope & Expectancy

Building the client's hope is one of

the essential tasks of therapy

Clients frequently enter therapy when their efforts to improve have been unsuccessful, leaving them feeling demoralized and hopeless. In this state, there is less motivation and agency to do the work to make things better. Alleviating a client’s hopelessness and instilling renewed hope is a primary task of psychotherapy (Frank & Frank, 1993). When therapy rekindles hope that a better future is possible, the client is re-energized to make positive changes - often in unique ways not specifically prescribed by the therapy.

Belief has the power to heal the mind and body. When a person believes a supposedly inert treatment or “placebo” will help them, it has been shown that substantial symptomatic relief occurs across a wide range of medical conditions (Brody & Miller, 2011). Jerome Frank (1993) looked at nonwestern healing practices that have no scientifically discernable therapeutic agent – such as shamanic rituals, faith healing, and early (often physically harmful) medications, and found people still improved if they believed in them.

Lambert’s review of the psychotherapy outcome literature determined that hope/expectancy was one of the “big four” common factors (along with the client, the relationship, and treatment models), finding it accounts for 15% of the improvement clients show in therapy (Asay and Lambert, 1999; Lambert 1992). A hopeful client is better able to invest in and utilize therapy. Clients who do not feel hope or expectancy are more likely to drop out of treatment or have suboptimal outcomes (Tambling, 2012). Recent meta-analytic studies of the extant research on hope in psychotherapy show that outcomes are improved when a client’s hope is mobilized in three key areas:

  1. Belief that they and their situation are not hopeless and can improve (hope).

  2. Belief that the treatment approach being used is credible and will be effective (expectancy).

  3. Belief that the therapist is credible and will be effective (expectancy).

(Constantino, Coyne, Boswell, Iles, & Vîslă, 2018; Constantino, Vîslă, Coyne, & Boswell,2018).

 

What the Research Says...

What it Means for Therapists

Therapists should assess, at the outset and throughout the course of treatment, a client’s level of hope for improvement and their expectancy that the therapist and treatment are credible and will be benefit them. Therapists should take deliberate steps to build the client’s hope and foster belief in the therapy process and therapist.

Recommendations from the Research

 

The research on hope was synthesized in two

2018 meta-analytic studies.

 

The studies found outcomes are strongly impacted by the client’s treatment expectations and how credible they perceive the treatment and therapist to be.

(Constantino, Coyne, Boswell, Iles, & Vîslă, 2018;  Constantino, Vîslă, Coyne, & Boswell,2018; Swift & Derthick, 2013).

Assess the client’s level of hope & expectancy both early on and throughout treatment.

1.

Regularly ask clients for positive and negative feedback about the treatment and the therapist.

2.

Present a convincing and compelling treatment rationale to bolster the client’s expectancy level (e.g. cite research support, wide-spread use, your past success in its use).

3.

Increase the client’s faith in the therapist's ability and willingness to help. Portray competence.

4.

Express hope and confidence in the client’s ability to improve.

5

Consider alternative treatment approaches if the client’s hope/expectancy is not mobilized.

6.