SHARE AND SHARE ALIKE: MUTUALITY OF EXPECTATIONS AND SATISFACTION

WITH THERAPY' PAUL J. MARTIN, ARTHUR L. STERNE AND MARILYNN L. HUNTER

Larue D. Carter Memorial Hospital Indianapolis, I d .

PROBLEM Factor-analytic studies of patients' expectations with regard to the behavior

of their therapists, summarized in Goldstein (5 ) , have identified a consistent triad of expected therapist behaviors: (1) nurturant - the therapist is concerned, supportive, and rewarding; (2) model -the therapist is a good, permissive listener; and (3) critic - the therapist is non-indulgent and judgmental. Studies of therapists' expectations with regard to the in-therapy behavior of patients are not as plentiful, but the available findings la) suggest that therapists tend to hold expectations about pa- tients that complement the expectations of patients about therapists.

Although it would seem that this complementary nature of patients' and therapists' expectations would facilitate investigations of the effects of mutuality of expectations, published studies of this facet of treatment are few. Chance") found that values and behaviors expected by patients of therapists were similar to those that therapists perceived the patients themselves to desire. The conclusion was drawn that mutuality of expectation may be one of the prerequisites to suc- cessful therapy. Appel (2) found that some clients demonstrated measurable changes in their expectations during therapy and others did not. Further analyses revealed that clients who showed changes had stated pretherapy expectations quite dif- ferent from those of their therapists and later had shifted to make them conform to those of the therapists. The shifting of expectations was attributed to a need for rapprochement between client and therapist during therapy. Lennard and Bern- steinc6) found a significant relationship between the degree of dissimilarity of expectations and the amount of strain on the therapy relationship. They con- cluded that mutuality of expectation produces harmony and stability and that large discrepancies may cause the therapy relationship to disintegrate completely.

The results of these studies suggest that mutuality of expectations may be an important variable in psychotherapy. The findings appear to involve several testable implications. In general, it seems that the satisfaction obtained,by patients and therapists from psychotherapy should be related to the mutuality of their expectations with regard to therapy conduct, insofar as satisfaction is related to rapprochement, harmony, and stability. Also, the greater the number of mutually held expectations, the greater should be the participant's satisfaction with therapy. Finally, studies by Apfelbaum(') and by Berzins, Herron and Seidmar~'~) suggest that expectations that involve nurturant, model, and critical behavior may be more basic and universal than others, and thus mutuality in these areas may be more productive of satisfaction than mutuality of expectation on less universal variables.

To test these implications, the nurturant and critical role expectations of relatively large numbers of patients and therapists were explored. Therapy dyads were grouped in terms of the degree of mutuality of their role expectations, and comparisons were made of the satisfaction with therapy reported by the dyads.

METHOD Subjects. The Ss were 144 patients and 77 psychotherapists who participated

on a voluntary basis. The patients were consecutive admissions to an intensive treatment psychiatric hospital between November of 1971 and May of 1972. The psychotherapist sample included 16 staff psychiatrists, 38 psychiatry residents,

This research was carried out in conjunction with a larger, ongoing follow-up program at Carter Hospital. I t WBS supported in part by grants from the Association for the Advancement of Mental Health Research and Education, Inc., Indianapolis, Indiana, and by NIMH Grant MH 23417-01.

678 Journal of Clinical Psychology, July , 1976, Vol. 32, N o . 3.

10 staff psychologists, and 13 predoctoral psychology interns. Neither patients nor therapists were aware of the exact nature of the study. All were informed that their responses would be used to help evaluate hospital treatment programs.

Procedure and Measures. After a short admission procedure, the patient was taken to the hospital admission ward, where he was given a 43-item Psychotherapy Expectancy Inventory to complete immediately. This procedure assessed patient expectations before they might be altered by the influence of the staff, other patients, or contact with a therapist. The Psychotherapy Expectancy Inventory, adapted from a scale devised by Lorr(’), required the patient to indicate the behaviors that he expected from his therapist during therapy.

Psychotherapists also completed a Psychotherapy Expectancy Inventory a t the outset of the study. It was identical to the patients’ scale, but the items were phrased to represent the obverse of those on the patients’. For example, the first item of the patient’s scale read, “The therapist will know exactly what I mean,” and the first item of the therapists’ read, “The patient will want you to know exactly what he means.”

During the week of his discharge, each patient completed the Psychotherapy Evaluation Questionnaire, a form adapted from Strupp, Fox and Lessler @). Scores on four items of the questionnaire were summated to yield a satisfaction score that could range from 4 to 22. The items called for patient to rate: (1) the benefit he derived from therapy; (2) his satisfaction with the results of therapy; (3) the degree of acceptance that he received from the therapist during therapy; and (4) the extent to which he would recommend psychotherapy to a friend with emotional problems.

Therapists also completed an Evaluation Questionnaire adapted from Strupp, et aZ.(B) after each of their patients was discharged. Again, scores on four items were summated to yield a satisfaction score that ranged from 4 to 24. On these items the therapist rated: (1) his enjoyment in working with that kind of patient; (2) the warmth of his feelings for the patient; (3) the quality of the working relationship with the patient; and (4) the overall pleasantness of experience with the patient.

TABLE 1. PATIENT NURTURANT EXPECTATIONS

Therapist’s Behavior r

1. 2. 3. 4. 5 . 6. 7. 8. 9.

10. 11. 12. 13. 14. 15. 16. 17. 18.

Will understand me even when I don’t express myself well. Will make me feel that he is the one person I can really trust. Will understand my problems and worries. Will seem to have a very real respect for me. Will show a real interest in me and my problems. Will realize and understand how my problems feel to me. Will make me feel free to say whatever I think. Will make me feel better after talking about my worries with him. Will be quick to praise and commend me when I am doing well. Will give generously of his time and energy to others. Will be protective of and really concerned about my welfare. Will seem to understand how I feel. Will be easy to talk to. Will offer me advice on my everyday problems. Will relate to me as though I were a companion. Will act as though we were coworkers on a common problem. Will show a real liking and affection for me. Will make comments that are right in line with what I am saying.

.72

.72

.71

.70

.69

.68

.68

.68

.67

.65

.63

.60

.60

.60

.59

.57

.52

.52

Share and Share Alike 679

Therapist-patient dyads were assigned to groups based on the results of analyses of the expectancy data. First, patients’ responses to the Expectancy Questionnaire were subjected to principal components factor analysis and Varimax factor rotation. Five interpretable factors emerged, two of which are relevant to this study. The first was labeled nurturant and is defined by items with high loadings that suggest that the therapist is expected to show understanding, support and encouragement. The second was labeled critical and is defined by items that sug- gest cold, critical, and quick-tempered therapist behavior. Items that comprise these factors and the factor loadings are presented in Tables 1 and 2. Identical analyses were conducted of the expectancy data provided by therapists. Two factors

TABLE 2. PATIENT CRITICAL EXPECTATIONS

Therapist’s Behavior T

1. Will act as though he were trying to outsmart me. 2. Will give the impression that he doesn’t like me. 3. Will talk down to me as if I were a child. 4. Will act smug and superior as if he knew all the answers. 5. Will be a difficult person to warm up to. 6. Will act as though I were dull and uninteresting.

.81

.79

.73

.59

.56

.52 7. Will become impatient when I make mistakes. .49 8. Will ignore some of my feelings. .44 9. Will seem glad to see the interviews finished. .32

represented very close complements of those identified in the analyses of the patient data. The first, also labeled nurturant, is defined by items that suggest a desire on the part of the patients for therapist understanding, encouragement, and concern. All (100%) of the items contained in this factor have complements in the patient nurturant factor. The second was labeled critical and subsumed items that suggest that the patient will provoke cold, critical, hostile behavior from the therapist. All of these but one (No. 6 in Table 4) have complements in the patient critical factor. Therapist expectancy factors are presented in Tables 3 and 4.

TABLE 3. THERAPIST NURTURANT EXPECTATIONS

Patient’s Behavior r

1. 2. 3. 4. 5. 6. 7. 8. 9.

10. 11.

12.

~~~ ~

Will desire your liking and affection for him. Will want your understanding of his problems and worries. Will desire your interest in him and his problems. Will demand that you be protective of and concerned about his welfare. Will desire praise and commendation when he is doing well. Will want to talk with you. Will desire large amounts of your time and energy. Will be deserving of a real respect. Will expect you to know what he means even when he doesn’t express himself well. Will seek your advice on his everyday problems. Will expect you to make comments that are right in line with what he IS saying. Will want you to know how his experiences feel to him.

.79

.68

.65

.63 -55 .53 .53 .50

.47

.42

.31

.30

680 Journal of Clinical Psychology, July, 1976, Vol. 32, No. 3.

An unweighted factor score was calculated for each patient and each thera- pist on both nurturant and critical factors. These were sums of scores on all in- dividual items subsumed by each factor, as shown in Tables 1-4. The factor scores then were ordered and divided a t the median for patients and for therapists, and each was assigned a rank, High or Low, on nurturant and critical factors. The ranking of each patient on both factors then was compared to the ranking of the patients’ therapist, and the patient-therapist dyads were assigned to groups that reflected the mutuality of their expectations. Patients and therapists first were compared for mutuality of nurturant expectations and were assigned to groups that reflected : (1) mutual High expectations; (2) nonmutual expectations in which either stated High, but his partner stated Low expectations; and (3) mutual Low nurturant expectations. Similar comparisons and groupings then were made for critical expectations.

TABLE 4. THERAPIST CRITICAL EXPECTATIONS

Patient’s Behavior 7

1. .75 2. Will provoke your impatience with his mistakes. .64 3. Will want you to outsmart him. .50

5. Will be somewhat dull and uninteresting. .41 6. .40

Will require treatment as if he were a child.

4. Will be cold; not a warm person. .44

Will make things that he tries to express difficult to understand.

RESULTS The patients and therapists from each dyad provided a measure of satisfaction

with therapy derived from the Psychotherapy Evaluation Questionnaire. These scores were subjected to analysis of variance to explore, first, the effects of the quality of mutually held expectations; that is, the effects of mutuality of nurturant and critical expectations considered singly. Second, the analyses assessed the effects of the quantity of mutually held expectations. Finally, the analyses tested the effects of patterns of mutually held nurturant and critical expectations con- sidered simultaneously.

Therapy dyads were assigned to three groups based on mutuality of nurturant expectations : mutual High, nonmutual, and mutual Low nurturant expectations. The satisfaction scores of the therapy dyads then were subjected to analyses. The results showed no differences in the satisfaction that the patients and therapists derived from therapy based on mutuality of nurturant expectations. The analyses of satisfaction scores of therapy dyads in mutual High, non-mutual, and mutual Low critical conditions were similar in their findings. Again, no significant dif- ferences were found among therapists’ satisfaction scores based on mutuality of critical expectations. For the patient sample it was found that marginally higher satisfaction scores were reported in the mutual Low critical condition than in the mutual High and nonmutual conditions ( F = 3.56; p < .05 for 2 and 119 df).

The second set of analyses was concerned with the quantity of mutually held expectations. Therapy dyad partners could hold similar expectations on both of the factors explored here, on one of them, or on neither. It should be noted that no consideration was given in these analyses to the specific quality (nurturant or critical) of expectation. Therapy dyads were grouped according to the number of expectations that they mutually held (2, 1, or 0) and patients’ and therapists’ satisfaction scores in these groups were subjected to analysis of variance. The results indicated that there were no significant differences in the satisfaction re- ported by patients or therapists regardless of the number of expectations that they mutually held.

Share and Share Alike 68 1

The final set of analyses dealt with patterns of nurturant and critical expecta- tions when both were considered simultaneously. Therapy dyads were assigned to nine subgroups that reflected all possible combinations of mutual and nonmutual nurturant and critical expectations. These groups are shown in Tables 5 and 6 along with means and SDs for satisfaction scores. Analysis of variance revealed that the patients in the mutual High nurturant - Low critical condition reported greatest satisfaction with therapy (Table 5). The mean satisfaction score for the patients in this condition was 21.00 (of 22.00 possible). Further analyses by t-tests revealed that the mean score for this condition was significantly higher than the means for all other conditions except three. These were the mutual Low nurturant - Low critical, mutual Low nurturant - nonmutual critical, and mutual High nur- turant - High critical conditions. Comparisons of the means, SDs, and Ns in these conditions with those in the remaining cells suggest that the lack of significant differences in these comparisons resulted from the small number of cases in these cells. TABLE 5. MUTUALITY OF NURTURANT AND CRITICAL EXPECTATIONS: PATIENT SATISFACTION

SCORIG

Critical Mutual-High Nurturant Nonmutual Mutual-Low

Mutual-High

Nonmutual

Mutud-Low

g = 18.8 SD = 2 . 8

N = 6

= 17.8 SD = 4 . 3

N = 14

x = 21.0 SD = 1.0 N = 7

x = 17.3 SD = 4 . 2 N = 18

x = 18.1 SD = 3 . 8 N = 32

x = 19.3 SD = 2 . 2

N = 16

x = 18.7 SD = 2 . 5

N = 18

x = 20.2 SD = 1 . 8 N = 9

x = 19.7 SD = 2 . 3 N = 3

P = 3.21; p < .01

The results of similar analyses of therapists’ satisfaction scores also revealed significant differences among the nine conditions (Table 6). Again it was found that the therapists in the mutual High nurturant - Low critical condition reported greatest satisfaction with therapy. The mean satisfaction score for the therapists in this condition was 19.50 (of 24.00 possible) and was significantly higher than all other means except two. These were the mutual Low nurturant - Low critical and the mutual High nurturant - High critical conditions. Again, minimal repre- sentation in these subgroups seems to have contributed to the lack of significant differences.

In light of the consistently high satisfaction scores of patients and therapists in the mutual High nurturant - Low critical condition, four additional analyses were conducted. These assessed the viability of an alternative explanation that does not involve mutuality of expectations as a necessity. It may be that patients and therapists in the High nurturant - Low critical condition were prone to report greater satisfaction with therapy regardless of the expectations of their therapy partners. To test this possibility, patients and therapists were separated into four groups that reflected all combinations of nurturant and critical expectations; that is, (1) High nurturant - High critical; (2) High nurturant - Low critical; (3) Low nurturant - High critical; and (4) Low nurturant - Low critical. The satisfaction scores of patients and therapists in these groups were subjected to analysis of variance. The analyses failed to support the alternative explanation. The High nurturant -

682

TABLE 6. MUTUALITY OF NURTURANT AND CRITICAL EXPECTATIONS: THERAPIST SATISFACTION

Journal of Clinical Psychology, July , 1976, Vol. 32, No. 3.

SCORES

Critical Mutual-High Nurturant Nonmutual

Mutual-High

Nonmutual

Mutual-Low

x = 16.0 SD = 3 . 7

N = 6 x = 14.5

SD = 3 . 2 N = 12

x = 19.5 SD = 1 . 3

N = 4

x = 15.1 SD = 3 . 7

N = 15

fi = 15.3 SD = 3 . 1

N = 25

x = 11.6 SD = 4 . 6

N = 5

It = 15.1 SD = 3 . 5

N = 15

x = 11.6 SD = 2 . 1

N = 7

x = 17.0 SD = .O

N = 1

F = 2.65; p < .02

Low critical condition was not associated with significantly higher scores for patients or for therapists when those anticipations were not also held by their therapy partners.

DISCUSSION Four interesting and noteworthy findings emerged from this study of the

effects of mutuality of patient and therapist psychotherapy role expectations on satisfaction with the psychotherapy experience. The first was that mutuality of patient and therapist nurturant and critical expectations, when considered singly, was not associated with greater satisfaction in psychotherapy. In general, it was found that when patient and therapist held similar anticipations with regard to the amount (high or low) of nurturant and critical behaviors that would occur during therapy, neither reported more satisfaction than was reported in cases that involved disagreement in expectations. These findings are inconsistent with earlier reports of greater harmony, stability, and freedom from strain when expec- tations were shared by patient and therapist. The results also found that increases in the number of areas in which mutuality existed were not linked to increases in satisfaction with therapy. Again this finding is inconsistent with some of the implications of previously reported studies. However, consideration of differences in outcome measures employed may help to resolve the conflict. In short, “har- mony,” “stability,” “rapproachment,” and “freedom from strain” in a therapeutic relationship may not be equivalents to satisfaction defined and measured in this study.

Second, mutuality of patient and therapist expectations was found to have a significant effect on satisfaction with therapy only when both expectation factors were considered together. The pattern that consistently produced the greatest satisfaction for both patients and therapists involved large amounts of warmth, acceptance, and understanding by the therapist coupled with little criticism, im- patience with mistakes, disinterest, and coldness. While these behavioral charac- teristics are in agreement with commonly held notions about the character of suc- cessful psychotherapy, it appears that their occurrence in concert is a necessary condition for reliably greater satisfaction of both participants. Mutually held anticipations for therapist nurturance alone, or for noncritical attitudes and behav- iors alone, are insufficient to produce significantly greater satisfaction.

Third, the pattern of mutually held expectations that was productive of most satisfaction did not occur with great frequency. Of the therapists, only 12% held High nurturant - Low critical expectations. In the patient sample, the pattern was

Share and Share Alike 683

somewhat more common; approximately 36% of the patients held expectations of this character. However, after the patients were assigned to therapists in the usual manner a t Carter Hospital, based on patient sex and therapists’ case loads, less than 6% of the therapy dyads had mutual High nurturant - Low critical ex- pectations. The most commonly occurring dyadic pattern involved patient-thera- pist nonmutuality of expectations on both factors studied. More than 25% of the therapy dyads fell into this category.

Finally, the similarity of nurturant and critical factors that emerged from the analyses of the patient and therapist expectancy data deserves attention. While there was not a 100% duplication of items subsumed by patient and thera- pist factors, it is clear that the basic interpretation of their expectancies is func- tionally identical. The close agreement between patients’ and therapists’ expec- tations is consistent with the conclusions reached by Berzins, et uZt3) in their fac- torial study. They concluded that therapists’ expectations “mirror the prevailing patient role expectations in our culture,” a reference to the nurturant - model - critic triad. The results of the present study are in accord with this conclusion.

SUMMARY This study is concerned with the effects of mutuality of role expectations on

the satisfaction that patients and therapists derive from psychotherapy. The role expectations of psychiatrically hospitalized patients and their therapists n-ere examined. Factor analyses of patients’ and therapists’ expectations produced similar nurturant and critical factors from both sources. Unweighted factor scores were calculated for each patient and therapist on these factors. The scores n-ere divided at the median and categorized, either High or Low, and therapy dyads then were assigned to groups based on the degree of mutuality of nurturant and critical expectations held by the therapy dyad partners. Ratings of satisfaction with therapy, derived from standard rating scales, served as outcome measures. The results indicated that neither patients’ nor therapists’ satisfaction with therapy was related to mutuality of nurturant or critical expectations when considered singly. Also, participant satisfaction was independent of the number of factors on which mutuality of expectation obtained. Only when mutuality was obtained on both factors, and these were considered simultaneously in specific pattern, i.e., High nurturant - Low critical, was significantly greater satisfaction reported. Differences between these results and previously reported findings that they ap- peared to contradict were discussed.

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