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A Meta-Analysis of the Association Between Patients’ Early Treatment Outcome Expectation and Their Posttreatment Outcomes

American Psychological Association
Psychotherapy
Authors:
Michael J Constantino at University of Massachusetts Amherst
Michael J Constantino
Andreea Vîslă
Andreea Vîslă
Andreea Vîslă
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Alice Coyne at American University
Alice Coyne
James F. Boswell at University at Albany, State University of New York
James F. Boswell
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Abstract

Patients' outcome expectation (OE) represents their belief about the mental health consequences of participating in psychotherapy. A previous meta-analysis of 46 independent samples receiving the treatment of at least 3 sessions revealed a significant association between more optimistic baseline, or early treatment, OE and more adaptive posttreatment outcomes (weighted r-.12 or d-.24; Constantino, Glass, Arnkoff, Ametrano, and Smith, 2011). The present study represents an update to that meta-analysis. To be included, articles published through June 2017 had to (a) include a clinical sample, (b) include a therapist-delivered treatment of at least 3 sessions, (c) include a measure of patients' own OE, (d) include at least 1 posttreatment mental health outcome not explicitly referenced as a follow-up occasion, and (e) report a statistical test of the OEoutcome association. The updated meta-analysis was conducted on 81 independent samples (extracted from 72 references) with 12,722 patients. The overall weighted effect size was r-.18, p .001, or d-.36, with high heterogeneity (I2-76%) and no evidence of publication bias. Several variables (patient age, measure type, and treatment manual used) moderated the OEoutcome association. These robust, replicated meta-analytic findings are discussed in light of methodological limitations and with regard to their practice implications.
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A Meta-Analysis of the Association Between Patients’ Early Treatment
Outcome Expectation and Their Posttreatment Outcomes
Michael J. Constantino
University of Massachusetts Amherst
Andreea Vîsla
˘
University of Zurich
Alice E. Coyne
University of Massachusetts Amherst
James F. Boswell
University at Albany, State University of New York
Patients’ outcome expectation (OE) represents their belief about the mental health consequences of
participating in psychotherapy. A previous meta-analysis of 46 independent samples receiving the
treatment of at least 3 sessions revealed a significant association between more optimistic baseline, or
early treatment, OE and more adaptive posttreatment outcomes (weighted r⫽.12 or d⫽.24;
Constantino, Glass, Arnkoff, Ametrano, & Smith, 2011). The present study represents an update to that
meta-analysis. To be included, articles published through June 2017 had to (a) include a clinical sample,
(b) include a therapist-delivered treatment of at least 3 sessions, (c) include a measure of patients’ own
OE, (d) include at least 1 posttreatment mental health outcome not explicitly referenced as a follow-up
occasion, and (e) report a statistical test of the OE⫺outcome association. The updated meta-analysis was
conducted on 81 independent samples (extracted from 72 references) with 12,722 patients. The overall
weighted effect size was r⫽.18, p⬍.001, or d⫽.36, with high heterogeneity (I
2
⫽76%) and no
evidence of publication bias. Several variables (patient age, measure type, and treatment manual used)
moderated the OE⫺outcome association. These robust, replicated meta-analytic findings are discussed in
light of methodological limitations and with regard to their practice implications.
Clinical Impact Statement
Question: This article examined the association between patients’ presenting, or early treatment,
expectation for a given treatment’s helpfulness and their outcomes after treatment ends. Findings:
Patient outcome expectation (OE) is an empirically supported correlate of treatment outcome that
therapists need to assess throughout treatment, attempt to heighten at treatment’s outset, and respond
to sensitively if/when it wanes. Meaning: The OE⫺improvement correlation increases the scientific
credibility of formerly ill-named “nonspecific” factors like expectancies; thus, there is sufficient
information to incorporate systematically OE-fostering and OE-restoring strategies into clinical
practice and training. Next Steps: Future research needs to (a) test strategies that causally enhance
patients’ OE to improve treatment efficacy and (b) illuminate both patient and therapist contributions
to patient OE to help tailor clinical practice and training.
Keywords: psychotherapy, patient outcome expectation, psychotherapy relationship, psychotherapy
outcome, meta-analysis
Supplemental materials: http://dx.doi.org/10.1037/pst0000169.supp
Patients’ expectations have long been considered a key ingre-
dient and common factor of successful psychotherapy (Frank,
1961;Goldfried, 1980;Goldstein, 1960a;Rosenzweig, 1936). In
his classic, Persuasion and Healing,Frank (1961) argued that
patients enter therapy because they are demoralized, and that for
any therapy to be effective, there must be within the patient a
mobilization of belief in the ability to improve. To Frank, this
positive outcome expectation (OE) precipitates a sense of remor-
Michael J. Constantino, Department of Psychological and Brain Sciences,
University of Massachusetts Amherst; Andreea Vîsla
˘, Department of Psychology,
University of Zurich; Alice E. Coyne, Department of Psychological and Brain
Sciences, University of Massachusetts Amherst; James F. Boswell, Department of
Psychology, University at Albany, State University of New York.
This article is adapted, by special permission of Oxford University Press,
by the same authors in J. C. Norcross & M. J. Lambert (Eds.) (2018),
Psychotherapy relationships that work (3rd ed.). New York, NY: Oxford
University Press. The Interdivisional APA Task Force on Evidence-Based
Psychotherapy Relationships and Responsiveness was cosponsored by the
APA Division of Psychotherapy/Society for the Advancement of Psycho-
therapy.
Correspondence concerning this article should be addressed to Michael
J. Constantino, Department of Psychological and Brain Sciences, Univer-
sity of Massachusetts Amherst, 135 Hicks Way, Amherst, MA 01003-
9271. E-mail: mconstantino@psych.umass.edu
This document is copyrighted by the American Psychological Association or one of its allied publishers.
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
Psychotherapy © 2018 American Psychological Association
2018, Vol. 55, No. 4, 473–485 0033-3204/18/$12.00 http://dx.doi.org/10.1037/pst0000169
473
... This impact of expectations can also be seen in the world of psychotherapy, where it plays a crucial role in treatment outcomes (Constantino, Arnkoff, Glass, Ametrano & Smith, 2011). In a recent meta analysis that included 72 articles, patient's expectations was found to be strongly associated with better treatment outcoms with moderating effect by the working alliance (Constantino, Vîslă, Coyne & Boswell, 2018). Past studies showd a positive correlation between positive patient's expectancties and a stronger working alliance that leads to better treatment outcomes (Vîslă, Constantino, Newkirk, Ogrodniczuk & Söchting, 2018). ...
... The expectations of patients have traditionally been regarded as a fundamental component and shared element contributing to the efficacy of psychotherapeutic interventions (Frank, 1961;Goldfried, 1980;Rosenzweig, 1936). Since then, more updated research also showed this trend and revealed additional richness that can explain the positive effect of patient's expectations on treatment outcomes (Constantino, Vîslă, Coyne & Boswell, 2018;Kube, Rief & Glombiewski, 2017). In theory, a lower or absent level of optimistic expectation (OE) may serve as a central manifestation of demoralization, which is a term coined by Frank (1961) to describe a state of psychological distress that can obscure an individual's perception of a brighter future. ...
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Background: Working alliance between therapist and the patient has been shown as an important feature of psychotherapeutic processes. There is need for identification of working alliance markers that could be predicted. Movement synchrony between the patient and the therapist is a one of the candidates. Developing a predictive model of movement synchrony may improve the quality of the treatment and could be implemented in other related fields. Aim: To develop a predictive model of movement synchrony based on patient’s characteristics using machine learning techniques. Method: Eighty six patients, suffering from depression were recruited offering free psychological treatment for depression. All patients answered intake questionnaires measuring baseline factors, and personal background information and then received sixteen video-recorded sessions of psychological therapy. Movement synchrony of each dyad (patient and therapist) was estimated using motion energy analysis which is quantifying movement based on the recorded session video frames. Then, patients were clustered to low\high synchrony’ groups. Results: Jaccard similarity analysis identified two patterns for nonverbal synchrony changes across sessions. One pattern (high synchrony group) showed initial high synchrony, followed by relatively large fluctuations, while the other (low synchrony group) displayed low synchrony initially with a small upward trend (N=22 and N=64, respectively). SVM with a radial kernel was used to classify patients into low and high synchrony groups based on the answers from intake questioneers, and achieved the accuracy 88% and Cohen’s kappa 0.68. Non-anxious attachment style, high expectations from the treatment, and gender match between patient and therapist were key predictors for high synchrony group. Conclusions: The study's results illuminate the complex dynamics of patient-therapist movement synchrony through a data-driven approach and machine learning techniques. Findings reveal the crucial roles of patient attachment style, treatment expectations, and gender congruence in influencing movement synchrony Importance of the study: These insights contribute significantly to understanding of movement synchrony's nuances, offering clinicians a predictive model for strengthening alliances and tailoring interventions, ultimately enhancing psychotherapy effectiveness.
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... Identifying these factors can have a positive impact on both psychotherapy research and practice. For example, client outcome expectations have been identified as one ingredient that is associated with client change (Constantino et al., 2018). Knowing this, psychotherapy researchers can work to identify the nuances of the role of expectations in predicting or explaining treatment outcomes (e.g., timing of expectations that best predict outcomes, expectation fluctuations over sessions, predictors of expectations) as well as ways to manipulate or improve them. ...
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