Psychology and Psychotherapy: Theory, Research and Practice

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Volume 87 Issue 4 (December 2014), Pages 373-464

Psychotherapy role expectations and experiences – Discrepancy and therapeutic alliance among patients with substance use disorders (pages 411-424)


The main aim of the study was to examine how the discrepancy between role expectations prior to psychotherapy and experiences of ongoing psychotherapy related to therapeutic alliance. We hypothesized that a similarity between patient role expectations and experiences would be associated with a stronger alliance. The study also examined whether different dimensions of psychotherapy role expectations predicted retention in psychotherapy.


A naturalistic study design was used with data collected prior to therapy and during the first 6 months of therapy.


Patients with substance use disorders completed the Psychotherapy Expectation Questionnaire‐short version (PEX‐S) at the time of therapy assessment. A subsample of these patients (n = 41; n = 24 in individual therapy and n = 17 in group therapy) provided data from therapy including psychotherapy experiences (also measured with PEX‐S) and therapeutic alliance, measured with Working Alliance Questionnaire‐short version.


For patients in group therapy, discrepancy between role expectations and experiences correlated negatively with alliance. Expectations prior to psychotherapy characterized by defensiveness correlated negatively with therapy retention.


The finding that disconfirmation of patients' role expectations in group therapy were associated with weaker therapeutic alliance highlights the importance of discussing psychotherapy expectations at an early stage in treatment. Expectations characterized by defensiveness predicted worse retention in psychotherapy, which indicates that the PEX‐S can be helpful in detecting patients at risk for dropout.

Practitioner points

  • In targeting a patient's role expectancies prior to treatment, possible discrepancies between patient and therapist are made visible and possible to examine.
  • Clarifying the patient's role expectations and the therapist's rationale might be a first step towards establishing a strong working alliance.
  • Surveying the patient's defensiveness tendencies at the beginning of therapy offers a chance to discuss possible fears and other obstacles concerning therapy.
  • Discrepancy between the patient's role expectations prior to treatment and their actual experiences of psychotherapy render valuable information that can be of use in the therapy process.

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