Introduction
“I don't believe psychological treatments will help me – but don't tell my therapist!”. Negative prognostic beliefs about the effectiveness of psychotherapy (negative
outcome expectations; OE) are problematic as they can impair the success of psychological treatments (Constantino et al.,
2018; Dew & Bickman,
2005; Greenberg et al.,
2006). Critically, OE are usually assessed with direct measures only (e.g., via questionnaires), which are subject to distortions by social desirability and various further motives (Greenwald et al.,
1998). Therefore, direct measures might not fully grasp the actual underlying expectations, and we may need additional, more unobtrusive measures that are not as easily controllable (Strack & Deutsch,
2004). This study aimed to develop and validate a single category implicit association test (SC-IAT) to measure the OE of psychotherapy indirectly.
Expectations in Psychological Treatments
OE can be defined as future-directed beliefs of a person if psychotherapy will effectively reduce their symptoms (Kirsch,
1985; Laferton et al.,
2017). They can be differentiated from generalized expectations, which encompass several contexts and are more similar to associations between two constructs (e.g., psychotherapy associated with effectiveness; Laferton et al.,
2017). Also, therapy motivation differs from OE since it includes a readiness to engage in psychotherapy but does not necessarily encompass effectiveness beliefs (Constantino,
2012; Norcross et al.,
2011). Some researchers define the credibility of treatment as a distinct construct from OE (Devilly & Borkovec,
2000). However, credibility could also be a prerequisite for expectations (e.g., if patients do not find a treatment logic, they cannot expect it to be effective for them; Panitz et al.,
2021).
Expectations have been assigned an increasingly central role in medical and psychological studies and treatments (Constantino et al.,
2018; Rief & Glombiewski,
2016; Rief et al.,
2022). Different researchers investigated if OE differ across sociodemographic characteristics and clinical conditions. Previous results demonstrated relationships between less positive OE with older (vs. younger) age, in men (vs. women), with lower (vs. higher) education, and with higher anxiety and depression (Cohen et al.,
2015; Constantino et al.,
2018; McHugh et al.,
2013; Silverman et al.,
2021; ten Have et al.,
2010; Vîslă et al.,
2019). However, these findings were very inconsistent across studies. Overall, patients with treatment experience expressed more positive OE than those who never experienced psychotherapy (MacNair-Semands,
2002; Silverman et al.,
2021). Thereby, satisfaction with the treatment was related to positive OE, whereas negative experiences were related to negative OE (Tran & Bhar,
2014).
Critically, negative OE were associated with adverse effects in clinical and psychotherapeutic practice, for instance, increased pain (Bingel et al.,
2011; Corsi & Colloca,
2017) or impaired effectiveness of psychotherapy (Constantino et al.,
2018; Dew & Bickman,
2005; Greenberg et al.,
2006). Consequently, we need reliable and valid measurements of OE to identify negative expectations so that we can change them and prevent their negative adverse effects.
The Measurement of Expectations
Past research on OE is typically based on direct measures (Laferton et al.,
2017). Direct measures openly ask the participants verbally or via questionnaires to what extent they assume psychotherapy to be effective. However, a different approach to assessing a construct of interest could be via indirect measures.
1 In indirect measures, the construct of interest (here: OE) is indirectly inferred from participants’ task performance in a given task.
Since mental health treatment is stigmatized, there are potential biases in the self-report measures of psychotherapy OE (Corrigan,
2004; ten Have et al.,
2010). For instance, if patients feel pressured to express positive expectations to satisfy their therapist but hold negative expectations, the directly measured expectations could be invalid (Grimm,
2010). This effect is not only present in psychological treatments but further well known in psychological studies. In psychological studies, the participants might respond in favor of the hypothesis to be a "good" participant (demand effect; Orne,
1962), which could distort the measured OE. Furthermore, some patients might have problems expressing their expectations directly. For instance, when patients do not want to, do not know, or are unable to express their true expectations because of a lack of introspective abilities (Nosek et al.,
2011). In these cases, an indirect measurement would be helpful because it might be more unobtrusive and not as easily controllable. Consequently, the measured OE might be less influenced by self-presentational distortions and the participant´s knowledge of their beliefs and attitudes (Greenwald et al.,
1998).
Another reason we might need indirect measures is that they could contribute to predicting health-relevant behavior. In particular, a comprehensive meta-analysis demonstrated that direct and indirect measures predicted behavior (for instance, an
obese +
low performance | normal weight +
high performance IAT predicted hiring decisions). Importantly, indirect measures predicted behavior more stable, independent of the study characteristics, target groups, and type of behaviors (Kurdi et al.,
2019; Rüsch et al.,
2009). Furthermore, when direct and indirect measures match, psychotherapy success might be most likely (Rief et al.,
2022). For instance, exposure success might be most robust when expectation change can be detected via both direct and indirect measures. In summary, these results suggest that indirect measures of OE could add value beyond the direct measure by contributing to predicting health-relevant variables.
Indirect Assessment of Expectations Toward Psychotherapy
Only three studies to date have investigated computer-based indirect measures to capture psychotherapy OE (Goguen et al.,
2016; Pfeiffer et al.,
2022; Silverman et al.,
2021). In particular, they used the Implicit Association Test (IAT), one of the most widely used indirect measurement methods (Greenwald et al.,
1998). In an IAT, participants are asked to assign words presented in the middle of the screen (e.g., “psychological treatment”, “useful”) as quickly as possible to categories shown left and right on the screen by pressing a key. In one block, “psychotherapy + effective” were assigned to the same key (and “medication + unhelpful” to another key). In the other block, “psychotherapy + unhelpful” were assigned to the same key (and “medication + effective” to another key). According to the IAT framework, faster responses in the “psychotherapy + effective” (and “medication + unhelpful”) block as compared to the “psychotherapy + unhelpful” (and “medication + effective”) block speak for positive psychotherapy OE (stronger associations between
psychotherapy +
effective | medication +
unhelpful compared to
psychotherapy +
unhelpful | medication +
effective). The OE IAT demonstrated moderate internal consistency (
r = 0.58; Silverman et al.,
2021) and reasonable construct validity indicated by the significant correlations between the indirect and direct measures (
r = 0.07–0.32; Goguen et al.,
2016; Pfeiffer et al.,
2022; Silverman et al.,
2021). Concerning the overall means, however, Silverman et al. (
2021) found positive psychotherapy OE, Goguen et al. (
2016) found positive medication OE, while Pfeiffer et al. (
2022) found no effect in the overall sample.
Critically, using this IAT paradigm, we can only interpret the results directly related to the used reference category. Positive psychotherapy OE means that participants perceived psychotherapy as more effective than medication. Positive medication OE means that participants perceived medication as more effective than psychotherapy. However, we can only interpret the relative preference of medication over psychotherapy (or vice versa). In the case of positive psychotherapy OE, both psychotherapy and medication could be assumed to be effective, with psychotherapy slightly more effective than medication. Alternatively, both could be assumed to be unhelpful, with medication slightly more unhelpful than psychotherapy. Conflictingly, no effect in the IAT could mean that the psychotherapy and medication are considered both very unhelpful or both very effective. Consequently, we cannot draw conclusions about the underlying psychotherapy expectations from this IAT. That is, in studies where medication might not be relevant or with patients not considering medication, we need a measure of psychotherapy OE independent of medication OE to investigate its influence on psychotherapy outcomes.
In order to rectify this problem and to make a statement about psychotherapy OE only, the single category IAT (SC-IAT) could offer a good solution. The SC-IAT uses only one target category and two attribute categories. It allows the measurement of associations between the target and attribute categories without directly referring to another category. The internal consistency in SC-IATs is usually smaller than in IATs (average of α = 0.80; Greenwald et al.,
2021) and self-reports but higher than in other indirect measurements such as evaluative priming (Karpinski & Steinman,
2006). In validation studies, the SC-IAT demonstrated good internal consistency (adjusted
r = 0.55–0.85) and validity (indirect-direct correlations
r = 0.02–0.38) in measuring soda preferences, stereotypes, attitudes toward homosexuality, and anxiety (Breen & Karpinski,
2013; Karpinski & Steinman,
2006; Stieger et al.,
2010). This is why we developed and tested a Therapy SC-IAT in the present study.
Critically, the IAT and SC-IAT have been found to be confounded by factors other than the construct of interest (e.g., cognitive skills, speed accuracy; see Klauer et al.,
2010 for further explanations of the method-specific variance). This is why it has been proposed to control for such method-related confounds by, for instance, adding a control (SC-) IAT unrelated to the construct of interest in the experimental setup (see Teige-Mocigemba & Klauer,
2015). If such a control (SC-) IAT shows the same effects as the newly developed target (SC-) IAT, this would mean that confounds of the measurement outcome of an (SC-) IAT rather than the to-be-assessed constructs itself drive the observed effects. To control such unwanted influences, we thus included an OE-unrelated Flower SC-IAT in our study.
Research Question
The present research aimed to develop and validate a SC-IAT for indirectly measuring OE toward psychotherapy. To this end, we assessed self-report (direct) measures of OE, a Therapy SC-IAT, and a control Flower SC-IAT (used in Klauer et al.,
2010) in a large heterogeneous sample. For the validation of the Therapy SC-IAT, we predicted that (i) psychotherapy is more strongly associated with effective than unhelpful (see Seewald & Rief,
2023; Silverman et al.,
2021), while Flowers is more strongly associated with positive than negative, (ii) the Therapy SC-IAT is positively correlated with the direct measures of OE (convergent validity), and that (iii) the Flower SC-IAT is positively correlated with the Therapy SC-IAT (method-specific variance), while it is not significantly correlated with the direct measures of OE (discriminant validity).
Since negative OE can impair outcomes, people at risk for negative OE should be identified. Therefore, we conducted a regression analysis to investigate if directly and indirectly measured OE vary across demographic characteristics and psychological disorders. Because of the inconsistency of previous study results, we investigated age, gender, nationality, education, previous psychotherapy experiences, current problems, anxiety, and depression exploratory without predefined hypotheses. Last, we analyzed the incremental validity by examining if adding the indirect measure to the direct measures as predictors for experiences with psychotherapy improves the model.
Discussion
To the best of our knowledge, this is the first study that developed and validated an online SC-IAT to indirectly measure the OE of psychological treatments. We conducted the Therapy SC-IAT, a (control) Flower SC-IAT, and three direct measures of OE in a large sample. The Therapy SC-IAT correlated with the direct measures of OE (except the CEQ; convergent validity) and did not correlate with measures of flower associations (discriminant validity). Furthermore, the indirect OE were positively associated with people who have (vs. have not) been in psychotherapy, even when we controlled for the direct measures of OE, indicating evidence for incremental validity of the Therapy SC-IAT.
In line with our hypotheses, psychotherapy was more strongly associated with effective than unhelpful, which ties well with the previous study of Silverman et al. (
2021), indicating more psychotherapy + effective associations compared to medication + effective associations. Our findings extend the previous evidence because we demonstrated positive indirectly measured OE independent of another reference category (e.g., medication in the study by Silverman et al.,
2021). Furthermore, the Therapy SC-IAT was positively associated with the Flower SC-IAT due to the method-specific variance. Also, the Therapy SC-IAT was not related to the direct measures of flower association, indicating the discriminant validity of the Therapy SC-IAT.
Moreover, the expected associations between the Therapy SC-IAT and the direct measures of OE (convergent validity) were significant (except with CEQ) but relatively low, with the Bayes factor indicating only anecdotal evidence. Such relatively low correlations between indirect and direct measures have been found in other areas, for instance, a previous Race SC-IAT (Karpinski & Steinman,
2006), homosexuality SC-IAT (Breen & Karpinski,
2013), or anxiety IATs (Egloff & Schmukle,
2002,
2004; Gschwendner et al.,
2008). Notably, the correlations between the Flower SC-IAT and direct OE measurements were insignificant. Because we consider the correlations of the Therapy SC-IAT and the direct measures of OE as unexpectedly low, we would like to discuss four possible reasons for this finding and ways to improve the indirect-direct correlations.
First, we shed light on the
D-score calculation Karpinski and Steinman (
2006) recommended. Using high error rates (> 20 %) as exclusion criteria resulted in high exclusion rates (11.3–11.6 % of all participants), which were comparable to other studies (5.4–13.6 %; Karpinski & Steinman,
2006). The current literature on IATs recommends including even participants with high error rates for the
D-score calculation (Greenwald et al.,
2003,
2021). However, a previous SC-IAT study filtered participants who were instructed to fake their responses by excluding high error rates (Karpinski & Steinman,
2006). Therefore, the error exclusion criteria might help filter participants pretending to have an alternative attitude, for instance, participants who want to disclose positive OE despite holding negative OE. In the supplementary material, we provide all analyses with the alternative
D-score calculation recommended by Greenwald et al. (
2021). With this scoring, the associations between the Therapy
D-scores and the CEQ turned significant, and the associations between Therapy
D-scores and all direct measures of OE slightly increased (by
r = 0.00–0.04 resulting in
r = 0.08–0.13 with the Greenwald scoring).
Second, we observed that the convergent and discriminant validity of the Therapy SC-IAT increased when participants completed the Therapy SC-IAT before the Flower SC-IAT (Tables S9 and S10 in the supplemental material display the correlations). To tackle these order effects, we randomized the order of both SC-IATs. Also, using an additional Flower SC-IAT in this study was relevant for validation. However, in further studies investigating OE, the Therapy SC-IAT can be used without other indirect measures, likely increasing indirect-direct correlations. Also, to obtain higher convergent and discriminant validity, we recommend implementing the Therapy SC-IAT at the beginning of studies investigating OE.
Third, the convergent and discriminant validity of the Therapy SC-IAT is higher in participants with no current psychological disorder compared to participants with a current psychological disorder by self-report (Tables S11 and S12 in the supplemental material display the correlations). The SC-IAT uses reaction times that can alter due to cognitive load or impairments, which are not uncommon in many psychological disorders. Consequently, it might be difficult for patients to respond to the demonstrated words within the response window of 1.500 ms. In this study, a high proportion reported having a current psychological problem (53.3 % in the indirect sample), while our Therapy SC-IAT still demonstrated reasonable reliability and validity. In addition, struggling with a current disorder did not influence the number of missing responses (> 1.500 ms), fast responses (< 350 ms), or error rates (all ps > .05). At this stage of understanding, we believe that the Therapy SC-IAT might be applicable to most psychological patients. However, including people with various psychological disorders increases the variance in the result patterns, further underpinned by the found differences across disorders (see supplemental material) and requests for disorder-specific analyses in future studies.
Last, we discuss the construct validity. The SC-IAT was developed to measure associations, meaning that the Therapy SC-IAT measured associations between
psychotherapy and
effective. It is unclear whether this is equivalent to a specific OE. For OE, one must not only associate psychotherapy with effectiveness but also expect it to be effective for their personal problem. Using the Therapy SC-IAT, a global attitude could have been measured instead (Karpinski & Steinman,
2006), which could overlap with help-seeking and motivation, reflected in the found associations with these constructs. Future studies could use the labels “I find effective” and “I find unhelpful” instead of effective and unhelpful for a more personalized SC-IAT (see Olson & Fazio,
2004), which might result in higher correlations between direct and indirect measures.
Nevertheless, we would like to point out that we did not aim for a 1:1 overlap of the indirect and direct measures. Instead, we wanted to develop an indirect measurement, which adds value to the measurement of OE and the prediction of therapy-relevant variables. In summary, although the indirect-direct correlations turned out lower than expected, this should not necessarily be interpreted as evidence against the Therapy SC-IATs validity (Stieger et al.,
2010). The developed Therapy SC-IAT might provide a useful complementary measure, and we recommend further investigating its validity considering the discussion points above.
Demographic Differences and the Influence of Experiences with Psychotherapy
Our exploratory regression analyses in this study revealed differences in indirectly and directly measured OE dependent on age, gender, and experience with psychotherapy. In all direct measures, more positive OE were associated with younger age, which aligns well with some studies (McHugh et al.,
2013) but contradicts other studies (Vîslă et al.,
2019). Younger participants could hold less stigma about seeking psychological treatments and expect them to be more effective (Silverman et al.,
2021). In both indirect measures, we found the opposite since older age was associated with more positive therapy and flower associations. However, this association could be driven by age-related slowing in the incompatible block (psychotherapy-unhelpful and flower-negative block) compared to the compatible block (psychotherapy-effective and flower-positive block) caused by declined cognitive abilities with older age (Hummert et al.,
2002; Sherman et al.,
2008).
In addition, more positive OE were associated with women compared to men, aligning with many other studies (Cohen et al.,
2015; McHugh et al.,
2013; Seewald & Rief,
2023; Silverman et al.,
2021; Vîslă et al.,
2019). This association could have social reasons again, as going to therapy meets more women than men stereotypes (e.g., talking about emotions; Silverman et al.,
2021).
Our exploratory evidence highlighted that more positive indirect and direct OE were associated with people who have been (vs. have not been) in previous psychotherapy, replicating previous findings (Goguen et al.,
2016; Silverman et al.,
2021). Flower
D-scores did not differ between participants with or without previous psychotherapy experiences, which indicates that the differences in the Therapy
D-scores are not driven by method-specific variance shared between the Flower SC-IAT and Therapy SC-IAT. Overall, the association between more positive OE with previous psychotherapy experience can be interpreted in two directions since we only have cross-sectional data. We can speculate that positive OE might have led to seeking psychotherapy in the past. Notably, the Therapy SC-IAT might add value to predict this behavior. Alternatively, experience with psychotherapy could have led to more positive expectations (Ladwig et al.,
2014; MacNair-Semands,
2002; Silverman et al.,
2021; ten Have et al.,
2010). Overall, our exploratory findings have the potential to inspire new theories in a bottom-up, data-driven way. Experimental or longitudinal studies should further disentangle the relationship between OE and experiences with psychotherapy under consideration of different psychological disorders.
Limitations and Future Directions
In the following, we discuss two possible limitations of the outlined study. First, even though we pretested our words for the SC-IAT in an independent study sample and achieved high typicality and indifferent frequency of the chosen words for our target and attribute categories, it was impossible to rule out word length differences. Psychotherapy words were longer than effective and unhelpful words, which might have influenced SC-IAT scores (Greenwald et al.,
2021). However, since we did not have to use another reference category, possible word-length effects would be equally distributed across the psychotherapy-effective and psychotherapy-unhelpful blocks in the Therapy SC-IAT, making unwanted biases unlikely.
Last, we cannot generalize the results due to our study sample. Almost 1/3 of our sample had therapy experience, and 1/2 had a current psychological problem. We donated one euro to a mental health organization for participating, which could have attracted more participants who already had experiences with psychological disorders or psychotherapy. Moreover, we did not ask about the participant’s ethnic background, but almost everyone had German citizenship and a high education. Based on previous studies, ethnic background could influence OE (Silverman et al.,
2021; Zhou et al.,
2019). Furthermore, mental health systems vary tremendously across countries. Since expectations can develop from experiences (Ladwig et al.,
2014; ten Have et al.,
2010), we assume that OE are dependent on the mental health system of the specific country. Therefore, our results should be expanded with a heterogeneous sample, including participants of different ethnic backgrounds and educational levels, investigating direct and indirect measures of OE under different healthcare systems.
This study is the first that developed an indirect measure of OE. In the future, researchers should try to answer the following questions: (1) In contexts where social desirability plays a central role or if participants are unable or unwilling to tell their therapist their OE, can indirect measures identify negative OE better than direct measures? (2) Can indirect measures predict help-seeking, health behavior, and outcomes better than direct measures? For these aims, our developed Therapy SC-IAT should be implemented in experimental and longitudinal designs.
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