It may not be the end of the world. At least not this time. Maybe this is an appropriate time to reflect on the role that hope plays in our lives and in the work that we do, and how we can keep its flame alive for our clients. Hopefully too, soon, in the words of Matt Haig, “We will be aware of all the luck we never saw.”

It’s March 13th, 2020. I’m in the departure lounge of Edinburgh airport, returning south after a three-day break with my wife. It’s spookily quiet, and the sense of impending threat that’s been building since we arrived has become impossible to ignore.

Ten days later the UK is fully locked down. Looking back, it’s hard not to smile at the hopelessly naïve belief that the three weeks initially proposed might be enough. In the intervening weeks and months there’s been a gradual, almost imperceptible sense of our worlds shrinking.

Where once we might have been prepared to carelessly fly halfway round the world, we now put greater planning into how to keep ourselves safe in the supermarket queue. That assumes we haven’t been shielding. I’m sure I’ve slowed down. It seems as if the air has somehow become denser, taking effort to push out of the way.

In my less optimistic moments, I confess I toyed with some pretty catastrophic ‘what if’s’. What if there’s no effective vaccine? What if people start to fight, not about toilet rolls, but food? What if this the end of the world as we know it? What if the world ends, not with a bang but with a dry cough? I could have created a pretty dystopian future had I stayed there too long.

A dystopian future narrowly averted…..

In the past two or three weeks, I’ve felt a sense of something lifting. The re-emergence of something I hadn’t fully noticed losing. Or, if not losing, then temporarily misplacing. I’m normally pretty good at optimism, which is remarkable given my rather dour Scottish Calvinist roots. But over the recent period, it’s felt increasingly tested. Not as tested as some, but tested, nonetheless.

Heaven knows we could all do with some hopeful news. An imminent end to the corrosive and polarising bile that’s spewed forth from the White House over the past four years. The prospect of a vaccine that’s effective against Covid-19. The possibility that we might yet snatch a deal from the jaws of an EU no-deal crash out.

The air seems lighter somehow. My energy levels have risen a notch. I’m making plans again, beyond which day I will visit the supermarket.

“I have felt optimistic about my future”

As I’ve felt my sense of optimism re-emerging, I’ve also been reflecting on the role of hope in the therapeutic work we do.

Embedded within the 34 item CORE Outcome Measure (CORE-OM) are two items that I’ve come to see as key indicators of client hope, and which I pay careful attention to.

A

I have felt despairing or hopeless (23)

A

I have felt optimistic about my future (31)

For those of you less familiar with the response options of the CORE measures they run from ‘Not at all’ through ‘Only occasionally’; ‘Sometimes’ and ‘Often’ to ‘Most or all of the time’. Feeling despairing or hopeless, ‘often’ or ‘most or all the time’ in the past week, or feeling ‘not at all’ optimistic about the future is a bleak place to find oneself in. Over time I’ve come to see these items as proxies for what might be otherwise unexpressed risk.

Hope, outcome expectation and evidence

We can think of hope, as it relates to therapy, as the extent to which the client harbours a hope or expectation that engaging in the process will bring about an improvement in some aspect of their lives. So, what impact does the presence of that hope or expectation have on outcome, and how can we foster it?

For those more statistically inclined, Michael Constantino and colleagues conducted a meta-analysis of client outcome expectations upon outcome itself in the excellent Psychotherapy Relationships that Work, edited by John Norcross. Aggregating the data from each relevant study, the authors found an effect size of (Cohen’s) d = 0.24, indicating a statistically significant positive relationship between high expectations of therapy and beneficial therapy outcomes.

Overall, this is a small but significant effect. To put it in context, the effect sizes for the working alliance and for therapy efficacy overall have been calculated at d = 0.57 (medium sized effect) and d = 0.8 (large effect) respectively. By contrast, comparisons between treatments yield effects closer to zero, and even “under the most liberal assumptions” the upper bound of the effect sizes are about d = 0.2

If numbers aren’t your thing, the message is simply this: clients that have higher expectations that therapy will make a positive difference will have better outcomes.

Fostering expectation of a positive outcome

Do clients come hopeful, or can we foster their positive expectations of the process? My view is maybe, and yes. I’ve come to believe that early messaging is important in building confidence, both in me and in the process, as well as motivation. These are four messages that I’ve found to be effective.

Therapy is remarkably effective. If we compare a group of people who’ve had therapy with a group that haven’t, those that have had therapy tend to be better off (psychologically) than 80% of those who haven’t. Therapy absolutely does work.

I have a good idea of the way out of here (but what do you think?). Two of the three elements of the working alliance are critical here, namely the establishment of goals and the direction of therapeutic travel (even if that changes). If the client weren’t to some extent lost, they wouldn’t be here. You need to build a compelling explanation for their current difficulty, and how you propose that you work together to resolve it.

If you have thoughts about how long this might take, I’d like to hear them. Clients often under-estimate the number of sessions likely to be required to achieve improvement. If your client thinks two sessions and you think twelve, you may start having issues from three onward. As one study I’ve written about before demonstrates, it’s useful to manage their expectations early.

If things are going to improve for you, we should see signs early. There’s a vast amount of evidence showing that early improvement in therapy is predictive of improvement overall, and that clients who don’t show early improvement are significantly less likely to improve later on.

Looking to the future

What will it feel like, I wonder, not to live in fear? I can’t think of a better way of putting it than this.

Until that time, I’m going to hunker down in my burrow. May you stay safe in yours.

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Posted by:Barry McInnes

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