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Patients’ expectations have long been considered a contributory factor to successful psychotherapy. Expectations come in different guises, with outcome expectations centered on prognostic beliefs about the consequences of engaging in treatment. This chapter defines outcome expectations and present assessment methods and clinical examples of outcome expectations. The research review includes a comprehensive meta-analysis (N = 8,016 patients across forty-six independent samples) of the association between pre- or early-therapy outcome expectations and posttreatment outcomes. The overall weighted effect size was d = .24, p 〈 .001, indicating a small, but significant positive effect of outcome expectations on adaptive treatment outcomes. This chapter also provides a narrative review of mediators of the expectation–outcome link and patient factors that relate to their outcome expectations. Finally, this chapter discusses limitations of the research base and offer therapeutic practices based on the findings.

This chapter discusses concept of advance care planning (ACP) in end of life care and explains the responsibilities of health care professionals in ACP. Properly conducted, ACP is likely to enable patients' previously stated preferences to be understood and taken into account once they have lost capacity. However, there is a risk that the ACP process may give rise to unrealistic patient expectations and in some patients to avoidable emotional distress.

For patients, the best relationships with their doctors involved the very things doctors identified as important, namely, trust, listening, emotional bonding, mutual respect, and accountability. Whereas doctors believed such strong relationships took time and a high degree of interaction with patients to establish, patients described it more as “in the moment” or sporadically emerging. They also indicated such relationships were rare. Patients also suffered from a variety of lowered expectations of their doctors that undermined their own thoughts on the prospects for strong connections with them. These lowered expectations took the form of an aversion to physician overuse of standardized medicine, along with beliefs that physicians are not easily accessible, and that primary care doctors are more “traffic cops” than multifaceted diagnosticians. These expectations feed into even further pessimism on the part of patients that they can or should have deep relationships with doctors, or that such relationships have value.

The forces impacting the doctor-patient relationship cede many care responsibilities from the individual primary care physician to the health care organization. Many physicians are now salaried employees of these organizations and report feeling a great deal of pressure from having to embrace population health management approaches that involve heavy use of quality metrics and care standardization. Aided by lowered expectations of their interactions with physicians, patient loyalties begin to shift toward the organization rather than any single doctor, as patients describe their lowered expectations and how these create opportunity to place their faith in a presumed ability by the organization to provide them with satisfactory care. This dynamic further undermines the dyadic bond potential between doctor and patient, and provides additional rationales for health care organizations to introduce retail tactics into their own interactions with patients, designed to build brand loyalty and meet more basic patient needs, such as convenience, in standardized ways.

The personal and intimate nature of the relationship between professional carer and patient and the poignancy of the potentially terminal outcome of the illness challenges the way therapists manage boundaries. Reciprocity of feeling and strong links can develop, especially in terminal stages, and self-disclosure can convey our sharing something of humanity. It is argued that the final decision for therapeutic action rests with the patient and not the professional, however senior. The patient’s dependence often smothers that right. There is responsibility towards the patient and not for him. The role of the professional is to share in the relevant problem, not necessarily to resolve it. Clarity about expectations and boundaries is more than agreeing on practical issues; it is about sharing the power in the relationship. For professionals working in an organisation, the employing institution will make its own demands about their use of time and resources. Dual responsibility to the patient and the institution can lead to ethical dilemmas.