Anthony R. Stone

SYSTEMATIC PREPARATION OF PATIENTS FOR PSYCHOTHERAPY. I. EFFECTS ON THERAPY BEHAVIOR AND OUTCOME.

OUR PREVIOUS studies have suggested that certain effects of psychotherapy and placebos on psychiatric outpatients may depend on the potentiation and activation of the patient’s favorable expectations.(Q) GOLDSTEIN(~) has pointed out the important role played by the patient’s expectations that he will improve, that he will receive a certain type of treatment, and that. he and the thergpist will behave in ctrtain ways. This paper reports a controlled study of the effects on psychiatric outpatients of a pre-treatment interview designed to clarify their expectations of psychotherapy and to increase the congruence of their behavior with therapists’ expectations as to how psychiatric patients should act. We tested the hypotheses that such an interview would favorably affect patient’s behavior during therapy and the outcome after four months of treatment. Because of the diversity and ambiguities of public conceptions of mental illness and psychotherapy, psychiatric patients reach the psychiatrist’s office with a wide variety of attitudes and expectations. Only the most sophisticated are perfectly clear about why they are there and what they expect (Ref. 4. p. 128). Less sophisticated patients may have unrealistic expectations for improvement: they may not understand their role in the therapeutic process@) and may be bewildered by a procedure that differs not only from usual medical treatment but from customary social interactions. As LENNARD and BERNSTEIN comment (Ref. 6, p. 26) : “Dissymetry of expectations not only interferes with the therapeutic task, but can actually lead to the premature death of a therapeutic system.” This might be an important reason why patients who are less educated and have a different cultural background than most therapists tend to terminate treatment prematurely.(‘W)

Time-focused role induction report of an instructive failure

Of the several possible components of a role induction interview this investigation examined “hope for improvement,” defining it in terms of a 4-week period when improvement could be expected. The hypothesis was that patients induced to expect improvement after 4 weeks of psychotherapy will report greater change at that point than other patients, whose expectations extend to a 4-month period. Fourteen psychoneurotic patients who appeared not to hold fixed time expectations regarding their rate of improvement, as revealed in a screening interview, were included in the study. All patients were administered a series of mock physiological tests; half of them were informed that the “tests” revealed they would experience improvement by the 4th week of psychotherapy and the remainder that improvement would be a gradual process over the 4-month psychotherapy period. All patients received a standard role induction interview and were assigned to one of four psychotherapists who saw the patients weekly. In addition to several scales for measuring the outcome of treatment, a relief expectancy questionnaire was administered prior to and immediately following the mock session. Outcome measures revealed no differences between the experimental and control groups at either the 4-week or termination points and the questionnaire findings demonstrated failure of time induction to produce anticipated shifts even immediately after that procedure. It is concluded that patients have quite definite prior expectations with respect to improvement, and these are not easily manipulated. The 4-week expectancy we sought to induce may be too abbreviated even for clinically naive patients. Also, the isolation of time for experimental emphasis may do violence to role induction as an integral process, and the effect may be dissolved in the surround of the many other principles presented in a general role induction procedure.