Patient characteristics and the therapist as predictors of depressed patients' outcome expectation over time: A multilevel analysis

Abstract

OBJECTIVE
Although there is an established link between patients' early positive outcome expectation for and their actual improvement from therapy, there is little research on patients' change in outcome expectation across therapy and both patient and therapist correlates of early outcome expectation level and change. The present study examined: (i) the overall trajectory of change in patients' outcome expectation through cognitive-behavioral therapy (CBT) for depression; (ii) patient characteristics as predictors of both initial outcome expectation and change in outcome expectation; and (iii) between-therapist effects in outcome expectation change.

METHOD
Depressed patients (N = 143) received a brief course of CBT. Outcome expectation was measured at screening, pretreatment, session 7, and session 14.

RESULTS
Outcome expectation linearly increased from screening to session 14. When controlling for other patient characteristics at intake, having previous depressive episodes was negatively associated with initial outcome expectation and higher well-being was positively associated with initial outcome expectation. When controlling for early alliance and early symptom change, outcome expectation change was predicted by previous depressive episodes. Finally, therapist effects emerged in outcome expectation over time.

CONCLUSIONS
Various depressed patients' characteristics predict initial outcome expectation level and change, with significant between-therapists' differences related to outcome expectation change. Clinical or methodological significance of this article: The present study contributed much-needed information on the pattern of change in outcome expectations, as well as on correlates of both early outcome expectation and outcome expectancy growth (for which almost no prior data exist). Having this information, clinicians may respond more appropriately to low or decreasing levels of outcome expectation and capitalize on its changeability. Moreover, the study revealed a therapist effect on outcome expectation, which pushes the field to a vital next wave of process-outcome research-i.e., moving beyond total correlations to parsing between-patient and between-therapist variability in clinical constructs and construct-outcome associations.