Attending to patient expectations in the early stages of the therapy process: an investigation of general medical practitioners’ perspectives of referral discussions and whether observed therapist attention to expectations predicts therapeutic alliance and therapy outcomes

Submission note: A thesis submitted in partial fulfilment of the requirements for the degree of Doctor of Clinical Psychology to the School of Psychology and Public Health, College of Science, Health, and Engineering, La Trobe University, Bundoora.

Clinical practice and empirical research inform each other in this piece of research that explores how general medical practitioners (GPs) and therapists work with patient expectations. The present body of research consisted of three studies. The first study explored GPs` attitudes towards psychological treatment and their perspectives on their discussions with patients when making referrals for psychological treatment. The focus was on how GPs attend to patient expectations of therapy. A sample of 43 GPs from Victoria, Australia provided both quantitative and qualitative data, describing their views of how they work with patient expectations during the referral discussion. Findings suggested that many GPs in this sample do attend to patient expectations when making referrals. Qualitative analyses suggested that expectations related to outcomes, roles and therapy processes were each mentioned as important by a proportion of the GPs surveyed. It was argued that GPs may offer a possible pathway for shaping patient expectations before therapy even commences. The second study involved the development of a new observational measure of therapists` attention to patient expectations, the first of its kind. This measure, which assessed attention to several types of expectations, was then used in the third and final study where it was applied to 43 audio recordings of first therapy sessions that were part of the Jacobson et al. (1996) component analysis of cognitive behaviour therapy (CBT) for depression. The third study explored how therapists work with patient expectations in the first therapy session and sought to answer the question of whether more attention to patient expectations in the first session enhances therapeutic alliance and improves therapy outcome. Contrary to the hypotheses, ratings of the therapists’ attention to patient expectations in the first session were not associated with higher observations of working alliance with the patient or with outcomes in terms of depression scores. The implications for both theory and clinical practice, and future research are discussed.