INFORMATION FROM: DUNCAN, B .L . , MILLER, S.D. , WAMPOLD,

B .E . , & HUBBLE, M.A . (EDS) . ( 2010 ) .   THE HEART & SOUL OF CHANGE: DELI VERING WHAT WORKS IN THERAPY   (2 N D  ED. ) .WASHINGTON, DC : AMERICAN PSYCHOLOGI CAL ASSOCIATION.

Psychotherapy Integration Unit 2: Common Factors

The Research Evidence for Common Factor Models

The following PowerPoints from Chapter 2 of the Duncan text will cover:I. A Brief History of PsychotherapyII. Psychotherapy Evidence for Specific

IngredientsIII. Common FactorsIV. Summary & Implications

I. A Brief History of Psychotherapy: Two Strands

1. First Strand: Medical Model2. Second Strand: Common Factors Model

First Strand: Medical Model

First focused on diagnosis of an illness and appropriate treatment Looked for organic causes Freud provided scientific explanations for mental

disorders for which there was one cure Process of medical model:

1. Diagnose the problem 2. Prescribe a treatment3. The treatment is responsible for the change

Freud & Medical Model were challenged by Behaviorists

First Strand: Medical Model

Behaviorists Believed mental disorders were the result of learning Although Behaviorists said they were separate from the

medical model, they conformed to the medical model. They still diagnosed the issue, prescribed a treatment, and

viewed the treatment as responsible for the change. Behaviorist’s Process:

1. Identifying the disorder, problem, or compliant 2. Finding the explanation for the issue3. Diagnosing current mechanisms that are supporting or

maintaining the issue4. Applying appropriate mechanisms of change (therapy) that

disrupts the maintenance of the issue5. Those appropriate mechanisms of change are responsible for

the benefits of therapy

First Strand: Medical Model

Asks the question: “What treatment is indicated for what disorder in what population?”

Implications Supports the use of a diagnostic manual (DSM) of possible

disorders Requires validation for treatments Supports identifying specific treatments for specific

disorders Evidence Based Treatments Empirically Supported Treatments

Views the applied treatment the only factor responsible for change

Potentially limits what approaches are understood to be effective

Second Strand: Common Factors

Emphases: Specific ingredients of treatments are relatively

unimportant Humanistic interaction of therapist and client is important Collaborative work between therapist and client Structure of treatment

Important figures: Saul Rosenzweig – Founder, published in 1936 Judd Marmor Jerome Frank Sol Garfield

Second Strand: Common Factors

Asks the question: “What are the common ingredients in all treatments for all disorders that we can apply to this person in this setting?”

Common Factors are… Critical for effective therapy The “heart and soul” of change in therapy

II. Psychotherapy Evidence for Specific Ingredients

Does Psychotherapy Work? – YES! Rigorous clinical History of benefits in naturalistic settings Many studies on many forms of psychotherapy show

that in general, psychotherapy does work.

Are Some Psychotherapies More Effective Than Others? - Maybe? Maybe not…

II. Psychotherapy Evidence for Specific Ingredients

Smith & Glass’s (1977) Meta-analyses on Effectiveness of Psychotherapy in general “Although at first it appeared that behavioral

treatments were superior… when confounding variables (such as the reactivity of the measures) were controlled, there was no significant differences among treatments” (p. 57)

Found all treatments to be equally effectiveConfounding variables in research

Researcher’s alliances Benefits of treatment “controls”

“Supportive counseling” is not treatment as usual

II. Psychotherapy Evidence for Specific Ingredients

Wampold (1997) looked at only comparison studies of two treatments All treatments were found to be equally effective Even treatments that were very different from each

other were as closely related in outcomes as those that were similar to each other.

Criticism of Wampold’s (1997) study Questions/focus was too broad Did not ask if certain treatments were more effective

for certain disorders or populations

II. Psychotherapy Evidence for Specific Ingredients

Isolated incidences have shown one treatment to be more effective than another

Wampold has continued investigation in to comparisons of treatment Meta-analyses suggest there is no evidence that one

treatment works better for anxiety than any other (Wampold, 2001, 2006)

Meta-analyses suggest equal effectiveness on PTSD reduction of… Prolonged Exposure Eye Movement Desensitization and Reprocessing (EMDR) Hypnotherapy Psychodynamic therapy Person- Centered therapy (Benish, Imel, & Wampold, 2008)

II. Psychotherapy Evidence for Specific Ingredients

“It appears that for the most prevalent disorders of adults and children, all treatments intended to be therapeutic are equally effective. It is important to note that treatments intended to be therapeutic are… Provided by a [trained] clinician who believes in

treatment Accepted by the client

[This] is contrary to the medical model” (p. 60)

II. Psychotherapy Evidence for Specific Ingredients

Is there evidence for specificity in psychotherapy? Placebo-controlled designs are the best way to

determine that answer Require blinding, indistinguishability, and randomization Easy in medical trails for drugs Not so easy in studies of psychotherapy

II. Psychotherapy Evidence for Specific Ingredients

Three major issues with empirical study in counseling/psychotherapyPsychotherapy trials can not be blinded

Placebos are not indistinguishable Researchers/Therapists are not blinded and are active

participants in treatment/non treatment All treatment has common factorsStructural equivalence can not be studied

between a treatment and a non-treatment

II. Psychotherapy Evidence for Specific Ingredients

Take Home Message about Specific Ingredients: There is “Little evidence for the specificity of any

psychotherapy” (p. 66) that makes a significant difference in treatment

III. Common Factors

Implicit common factors of all therapies (Rosenzweig, 1936) – Not comprehensive list Inspiring or stimulating aspects of the therapist’s

personality Reintegration of personality through the systematic

application of some therapeutic ideology Implicit psychological processes such as catharsis or

social reconditioning The reformulation of psychological events

III. Common Factors

Common factors of psychotherapy are intertwined with each other and difficult to categorize

Research points to creating a good therapeutic alliance for best outcome results

Questions to ask to discover common factors What are the characteristics of effective therapists? What are the characteristics of effective therapeutic

alliances?

III. Common Factors

Common Factors of effective therapeutic alliances Client expectations of the benefits of therapy Agreement between client and therapist about the

goals and tasks of therapy Client accepts the Myths and Rituals of therapy (more

on next slide)

III. Common Factors

Myth & Ritual (Frank & Frank, 1991) Myth- rational for treatment

Explanation of client’s difficulties Not necessarily based in truth or science, but has to be

acceptable to the client and treatment provider Ritual – therapeutic actions

Structure and components of specific treatment Not necessarily based in truth or science, but has to be

acceptable to the client and treatment provider

IV. Summery & Implications

Clinical trails comparing two treatments consistently show that both treatments are more effective than no treatment

Research should focus on the process of therapy

Particular treatments should not be mandated

Clinicians should be held accountable for outcomes