Expected Engagement with Psychological Therapy: The Development of a Measure and Implementation as a Predictor of Therapy Outcome

Psychotherapy services face several challenges, one of which is to improve clients’ outcomes following therapy. This thesis aimed to better understand which pre-therapy client factors predict outcomes with particular psychotherapies. A systematic review of client factors that predict therapy outcome was conducted, which identified client expectations of therapy as a promising predictor of therapy outcome. This thesis therefore aimed to develop a programme of studies investigating client expectations of therapy. In order to build on the existing expectations literature, a previously unexplored aspect of expectations- expected engagement- was the research focus. The first aim of this thesis was to develop a valid and reliable measure of expected engagement. The Sheffield Expected Engagement with Therapy Scale (ShEETS) was devised and tested with three independent samples, from which acceptable validity and reliability were established. The next aim was to examine the use of the ShEETS as an outcome prediction tool for depressed clients. Results showed that those who rated cognitive therapy as more expected to engage them, but less credible, had more symptomatic improvement in Cognitive Behavioural Therapy (CBT). There was no significant effect of expected engagement on symptomatic improvement for those who received a person-centred therapy, known as Counselling for Depression (CfD), and no effect on therapy completion for either group. In the final study, levels of engagement during CBT and CfD were rated to understand whether observed engagement mediated the relationship between expected engagement and symptomatic improvement. However, the study did not find evidence to support this hypothesis. The findings of this research indicate that there may be potential for the predictive effect of expected engagement on symptomatic improvement in CBT. The implications of these findings are discussed in relation to the existing literature on expectations and prediction of therapy outcomes.