Not Just Nonspecific Factors: The Roles of Alliance and Expectancy in Treatment, and Their Neurobiological Underpinnings

Abstract

Therapeutic factors such as alliance and expectancy have been found to greatly affect treatment outcome in both psychotherapy and psychopharmacotherapy. Often, these factors are referred to as nonspecific because of their common roles across treatment modalities. Here we argue that conceptualizing such factors as nonspecific is not accurate at best, misleading at worst and may undermine treatment outcome across various modalities. We argue that alliance and expectancy contain both a trait-like common factor component and a state-like specific effect, and that it is clinically, conceptually and methodologically critical to disentangle the two. In other words, both alliance and expectancy may also function as active ingredients of treatment, leading to better outcome. We review the literature regarding the neurobiological underpinnings of alliance and of the expectancy effect, and suggest how future studies on the neurobiological basis of these effects can shed further light on the potentially distinct mechanisms of the trait-like and state-like components of each therapeutic factor.

It's the therapist and the treatment: The structure of common therapeutic relationship factors

“…This distinction between therapist and treatment, from the patient´s perspective, might be an important piece of the puzzle in regards to understanding the therapeutic process. The two factors appear clinically meaningful and relevant for the daily use in therapy, and it is natural to assume that the therapist is able to influence processes related to both factor 1 and to factor 2 (Constantino et al, 2012;Coyne et al, 2021;Vîslăet al, 2019;Zilcha-Mano et al, 2019). For instance, a therapist might interpret low scores on therapist confidence as an indication of having to practice his/her interpersonal skills (i.e., expressing empathy, communicating in a competent and verbally fluent manner and enabling direction in the therapeutic process).…”

Significance of Participants’ Expectations in Managing the Placebo Effect in Antidepressant Research

“…This relationship may be implicit proof that therapeutic responses in antidepressant studies are driven by participants’ expectations, more closely, their reverse expectations—the study participants’ belief that they are assigned to the placebo intervention arm, which is supposed to represent a neutral intervention (8, 10, 11, 13). Similar relationships may also be identified across a spectrum of conditions and treatments and have been attributed to a genuine placebo effect (14). Importantly, if the placebo intervention represents a valid epistemological tool (currently under debate), these probabilities should be considered when extricating the true efficacy of antidepressants in placebo-controlled studies (10).…”

“…These pathologic expectations are perpetuated and remain refractory to any form of adaptation (28). In other words, expectations may be deconstructed to trait-like (inter-individually) and state-like (intra-individually) variable components while retaining different precursors, moderators, mediators, predictive power, and manipulative potential (4, 14, 27). Finally, expectations are dynamic, are time and context dependent, and may involve higher-order and lower-order mechanisms that decode contextual information (7).…”

Influence of motivational placebo-related factors on the effects of exercise treatment in depressive adolescents

“…Major psychological mechanisms of the placebo-related responses are beliefs and expectations, expectancies (as a subset of the prior) and classical conditioning [19,20]. Expectation is a conscious cognitive process including a positive anticipation of the effect of an applied treatment [21][22][23]. Whereas negative anticipation and cognition concerning the effects of a treatment generate the so called "nocebo effect" [21].…”