Optimising the therapy experience

Addressing a client’s expectations of therapy

I had a client who entered therapy with a very specific idea of an ideal outcome which I could see would be impossible to achieve.

Clients begin therapy for many reasons, via a number of routes, and with varying prior experience of therapy; consequently, their expectations can vary enormously. As a therapist, whatever your orientation you probably start the therapy with more information about what to expect than your client. You have a correspondingly greater responsibility for helping to shape their expectations to what is reasonable. There are three overlapping areas of expectation you should address:

  1. In general terms, what outcomes can therapy expect to achieve? Is a 100% ‘cure’ possible, or even theoretically conceivable? What proportion of therapy clients (your own, if you have the figures) report that their initial problems have disappeared by the end of therapy? What proportion have improved but are still left with some difficulties? What is the likelihood of no change or even of deterioration? What are the possible ‘side effects’ of therapy?
  2. What can the client expect therapy to involve? I think it would have been helpful to be more explicit with my patient so that she knew what was expected of her. - Therapist Closely linked with the issue of contracting for therapy, addressing these expectations early on can help clients adapt to therapy and decide whether or not it is for them.

The above two areas probably need addressing in the first one or two sessions of therapy as you establish the working relationship between you. Once the relationship is established, a third more precise area of expectation needs to be covered:

  1. What specific outcomes, goals or objectives do we expect to aim for in this therapy? Different orientations of therapy will vary in how precise and specific it is appropriate to be here. But whatever your orientation, it is helpful to specify in advance what shared, negotiated outcome you are working towards together. This can of course be renegotiated as required, but one of the strongest predictors of good outcome and satisfaction with the process is for the client and therapist to agree on shared goals.

The timing of this third point will depend to some extent on the kind of therapy. In a fixed term therapy of (say) eight sessions this probably needs addressing in the first session. In a longer therapy this is less urgent but it might be appropriate to agree a review after an agreed trial number of sessions and for some goals to be negotiated at that review.

Goal attainment measures such as the Psychlops or that contained in the CORE system can be helpful in establishing and measuring progress towards such goals.