Lecture 4 - Common Factors and the Therapeutic Relationship

Question 1

What are common factors?

Answer 1

➢Factors that characterize psychotherapy, in general
▫Examples: therapeutic alliance, empathy, expectation for improvement, therapist skills
➢Contrast with factors that are specific or unique to a particular form of therapy
▫Examples: Dream analysis in Psychoanalysis; Exposure in Behaviour Therapy; Cognitive restructuring in CBT

Question 2

Common Factors: History

Answer 2

➢Saul Rosenzweig(1936)
▫Dodo bird verdict
-from Alice and Wonderland
-all therapies helpful and all must be recognized

➢Jerome & Julia Frank: Persuasion and Healing (1963)
▫“Healing and persuasive power of therapy depends on features shared by all schools”
▫Goal of therapist is to:
Clarify symptoms and problems
Inspire hope
Facilitate experiences of success and mastery
Stir patient’s emotions
▫As a result, patient becomes “remoralized” –increase sense of power to change self or environment

Contemporary
➢Bruce Wampold: Contextual Model
▫Pathways through which psychotherapy exerts effect
▫Initial therapeutic relationship
“First impression”
More clients drop out of therapy after first session than any other time point
▫“Real” relationship
Personal relationship marked by genuineness and perception that befits the other
▫Expectations (that treatment is gonna be helpful)
“Remoralization”
Participating in psychotherapy will help with coping, which motivates action
▫Treatment that elicits healthy patient actions will be effective

Question 3

Common Factors: Evidence

Answer 3

➢Therapeutic Alliance
▫Affective bond
▫Agreement on end goals
▫Agreement on in session tasks
➢Measured using Working Alliance Inventory
➢Most studied common factor
▫Relationship between early therapeutic alliance and therapy outcome: r = .27 (medium effect)

➢Empathy
▫Process by which an individual can be affected by and share emotional state of another, assess reasons for the other’s state, and identify with other by adopting his/her perspective
▫Related constructs
Positive regard/affirmation
Congruence/genuineness
▫Empathy, rated by clients, therapists, and observers, correlates with therapy outcome (rs= .32, .25, and .20, respectively)

➢Expectations
▫Explanation of patient disorder, rationale for treatment, participating in therapeutic actions
▫Expectations are basis of placebo effect
▫Relationship between patient expectations and outcome, r= .12 (small effect)

➢Therapist effects
▫Do some therapists produce better outcomes, regardless of nature of patients and treatments delivered?
▫Within a treatment, some therapists will be more skillful than others
▫In clinical trials, therapist effects are small-to-moderate (d= .35)
More control over treatment delivery
▫In naturalistic settings, therapist effects are moderate (d= .55)

➢Facilitative interpersonal skills (FIS)
▫8 skill domains
Verbal fluency, emotional expression, persuasiveness, warmth/positive regard, hopefulness, empathy, alliance bond capacity, alliance-rupture-repair responsiveness
▫Thought to be pre-existing skills that predict client outcome
▫Self-report assessments can be biased
Performance-based assessment involves therapists responding to standard client scenarios, with responses recorded and coded for FIS domains
➢Anderson et al. (2016); Journal of Consulting and Clinical Psychology
▫44 Clinical Psychology PhD students
Self-reported social skills and completed FIS performance task in first 2 weeks of program
▫117 clients receiving treatment at a university training clinic
Students began seeing clients in second year of program
▫Clients receiving treatment corresponding to a range of different theoretical orientations
▫Reported on general symptoms and functioning each session
Results:
▫Higher FIS therapists, as determined at beginning of program, had clients with better outcomes in years 2, 3, and 4 of program
▫Effect was present for therapies of shorter (< 8 sessions), but not longer(> 16 sessions) durations
▫Therapist FIS may contribute to sudden gains early in therapy
What suggests:
Therapist FIS
-can contribute to early gains in therapy therefore… may not need to continue therapy for as long
-early ones, probably dropping out. When retain for longer, differences go away

Question 4

Common VERSUS Specific Factors

Answer 4

➢Evidence that favours common over specific factors
▫Any therapy is better than no therapy
▫Therapies often do not differ when pitted against one another
Differences that do exist often reduced when controlling for investigator allegiance (the researcher is the one who invented the therapy and is investigating it)
▫Adherence to specific therapy techniques unrelated to outcome
Null correlation between therapist fidelity measures and patient response
➢However….
▫No controlled studies exist to demonstrate that common factors are sufficient (!) for CAUSING therapeutic change (only correlational research)

➢Lubrosky et al. (2002); Clinical Psychology: Science and Practice
▫“The Dodo Bird Verdict is Alive and Well –Mostly”
▫Examination of 17 meta-analyses comparing different forms of psychotherapy to one another
▫Mean effect size: d= .21
▫Controlling for investigator allegiance reduces effect: d= .1215 (small)

➢Barth et al. (2013); PLOS One
▫Meta-analysis of 198 studies of seven psychotherapies for depression
▫Each intervention was more effective than waitlist control: ds = .62-.92
▫Effect sizes similar for different interventions, with one exception IPT (interpersonal therapy = bigger!)

➢Tolin(2010); Clinical Psychology Review
▫CBT versus other psychotherapies (interpersonal, psychodynamic, supportive)
▫Only comparisons considered “bona fide” (Actions on part of client are gonna elicit potential for change) treatments versus “intent-to-fail” conditions
▫26 studies
▫CBT superior to psychodynamic therapy: d= .28
▫CBT only significantly superior for depression and anxiety
▫Investigator allegiance to CBT correlated with strength of study effect, but CBT remained superior

➢Mulder, Murray, & Ruckledge(2017); Lancet Psychiatry
▫More similarities than differences
Specific factor theorists agree that common factors are important and therapeutic relationship is necessary (but not sufficient)
Common factors theorists have tightened definition of “bona fide” treatments
Common factors theorists acknowledge that some specific techniques are more effective than others for particular conditions
▪ex: exposure for anxiety disorders
▫Moving forward…
Prioritize treatment process over treatment outcome research
▪Focus not on WHAT works, but HOW it works
Remember that evidence for efficacy =/= validity of treatment
▪Remain skeptical!
Train students in therapeutic principles of CBT
▪Focus on specific techniques when evidence shows therapeutic benefit

➢Debate between
▫Bruce Wampold(Common Factors Theorist) ▫Peter Fonagy (Creator of Mentalization-Based Therapy, a psychodynamic treatment for borderline personality disorder)
youtube video