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Towards a Taxonomy of Common Factors in PsychotherapyResults of an Expert Survey Wolfgang Tschacher,* Ulrich Martin Junghan and Mario Pfammatter Department of Psychotherapy, University Hospital of Psychiatry, University of Bern, Bern Switzerland Background: How change comes about is hotly debated in psychotherapy research. One camp considers non-specicor common factors, shared by different therapy approaches, as essential, whereas researchers of the other camp consider specic techniques as the essential ingredients of change. This controversy, however, suffers from unclear terminology and logical inconsistencies. The Taxonomy Project therefore aims at contributing to the denition and conceptualization of common factors of psychotherapy by analyzing their differential associations to standard techniques. Methods: A review identied 22 common factors discussed in psychotherapy research literature. We conducted a survey, in which 68 psychotherapy experts assessed how common factors are implemented by specic techniques. Using hierarchical linear models, we predicted each common factor by tech- niques and by expertsage, gender and allegiance to a therapy orientation. Results: Common factors differed largely in their relevance for technique implementation. Patient engagement, Affective experiencing and Therapeutic alliance were judged most relevant. Common factors also differed with respect to how well they could be explained by the set of techniques. We present detailed proles of all common factors by the (positively or negatively) associated techniques. There were indications of a biased taxonomy not covering the embodiment of psychotherapy (expressed by body-centred techniques such as progressive muscle relaxation, biofeedback training and hypnosis). Likewise, common factors did not adequately represent effective psychodynamic and systemic techniques. Conclusion: This taxonomic endeavour is a step towards a clarication of important core constructs of psychotherapy. Copyright © 2012 John Wiley & Sons, Ltd. Key Practitioner Message: This article relates standard techniques of psychotherapy (well known to practising therapists) to the change factors/change mechanisms discussed in psychotherapy theory. It gives a short review of the current debate on the mechanisms by which psychotherapy works. We provide detailed proles of change mechanisms and how they may be generated by practice techniques. Keywords: Common Factors, Psychotherapy Techniques, Therapy Process, Change Mechanism, Theory of Psychotherapy INTRODUCTION Psychotherapy research has settled the question of the efcacy of psychotherapy to the positive since several years. Numerous studies and meta-analyses have demonstrated that psychotherapy works for most forms of psychopath- ology. The eld has arrived at a consensus that psycho- therapy is more effective than no treatment and than placebo controls (Lambert & Ogles, 2004). Yet sources of considerable disagreement remain: they concern the relative efcacy of different psychotherapy approaches as well as, importantly, the mechanisms by which psycho- therapy becomes effective. In this context, major contro- versies have addressed the Dodo-bird verdict(i.e. all psychotherapy approaches have similar benets; hence, all must have prizes) and the role of common versus specic factors of psychotherapeutic change (Wampold, 2001; Beutler, 2002; Chambless, 2002; Luborsky et al., 2003). This controversy has split the eld into two oppos- ing camps: one camp attributes therapeutic change to specic ingredientsand factors (DeRubeis et al., 2005), and the other favours a common-factor model (Wampold et al., 2001). *Correspondence to: Prof. Dr. Wolfgang Tschacher, Department of Psychotherapy, University Hospital of Psychiatry, University of Bern, Laupenstrasse 49, 3010 Bern, Switzerland. E-mail: [email protected] Clinical Psychology and Psychotherapy Clin. Psychol. Psychother. 21, 8296 (2014) Published online 6 November 2012 in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/cpp.1822 Copyright © 2012 John Wiley & Sons, Ltd.

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  • Towards a Taxonomy of Common Factors inPsychotherapyResults of an Expert Survey

    Wolfgang Tschacher,* Ulrich Martin Junghan and Mario PfammatterDepartment of Psychotherapy, University Hospital of Psychiatry, University of Bern, Bern Switzerland

    Background: How change comes about is hotly debated in psychotherapy research. One camp considersnon-specic or common factors, shared by different therapy approaches, as essential, whereasresearchers of the other camp consider specic techniques as the essential ingredients of change. Thiscontroversy, however, suffers from unclear terminology and logical inconsistencies. The TaxonomyProject therefore aims at contributing to the denition and conceptualization of common factors ofpsychotherapy by analyzing their differential associations to standard techniques.Methods: A review identied 22 common factors discussed in psychotherapy research literature. Weconducted a survey, in which 68 psychotherapy experts assessed how common factors are implementedby specic techniques. Using hierarchical linear models, we predicted each common factor by tech-niques and by experts age, gender and allegiance to a therapy orientation.Results: Common factors differed largely in their relevance for technique implementation. Patientengagement, Affective experiencing and Therapeutic alliance were judged most relevant. Commonfactors also differed with respect to how well they could be explained by the set of techniques. Wepresent detailed proles of all common factors by the (positively or negatively) associated techniques.There were indications of a biased taxonomy not covering the embodiment of psychotherapy(expressed by body-centred techniques such as progressive muscle relaxation, biofeedback trainingand hypnosis). Likewise, common factors did not adequately represent effective psychodynamic andsystemic techniques.Conclusion: This taxonomic endeavour is a step towards a clarication of important core constructs ofpsychotherapy. Copyright 2012 John Wiley & Sons, Ltd.

    Key Practitioner Message: This article relates standard techniques of psychotherapy (well known to practising therapists) to the

    change factors/change mechanisms discussed in psychotherapy theory. It gives a short review of the current debate on the mechanisms by which psychotherapy works. We provide detailed proles of change mechanisms and how they may be generated by practice

    techniques.

    Keywords: Common Factors, Psychotherapy Techniques, Therapy Process, Change Mechanism, Theory ofPsychotherapy

    INTRODUCTION

    Psychotherapy research has settled the question of theefcacy of psychotherapy to the positive since several years.Numerous studies and meta-analyses have demonstratedthat psychotherapy works for most forms of psychopath-ology. The eld has arrived at a consensus that psycho-therapy is more effective than no treatment and thanplacebo controls (Lambert & Ogles, 2004). Yet sources

    of considerable disagreement remain: they concern therelative efcacy of different psychotherapy approachesas well as, importantly, the mechanisms bywhich psycho-therapy becomes effective. In this context, major contro-versies have addressed the Dodo-bird verdict (i.e. allpsychotherapy approaches have similar benets; hence,all must have prizes) and the role of common versusspecic factors of psychotherapeutic change (Wampold,2001; Beutler, 2002; Chambless, 2002; Luborsky et al.,2003). This controversy has split the eld into two oppos-ing camps: one camp attributes therapeutic change tospecic ingredients and factors (DeRubeis et al., 2005),and the other favours a common-factor model (Wampoldet al., 2001).

    *Correspondence to: Prof. Dr. Wolfgang Tschacher, Department ofPsychotherapy, University Hospital of Psychiatry, University of Bern,Laupenstrasse 49, 3010 Bern, Switzerland.E-mail: [email protected]

    Clinical Psychology and PsychotherapyClin. Psychol. Psychother. 21, 8296 (2014)Published online 6 November 2012 in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/cpp.1822

    Copyright 2012 John Wiley & Sons, Ltd.

  • The specic-ingredients camp focuses on techniques asthe causal agents of therapeutic change. In recent years,specic ingredients have become the basis of practiceguidelines and of empirically supported therapies inevidence-based medicine (Chambless & Ollendick, 2001).The opposing camp emphasizes that core therapeuticfactors shared by different approaches account formost of the benets achieved in psychotherapy. Thesefactors of therapeutic change are called non-specic orcommon and thus may explain the Dodo-bird verdict.Common factors are not theoretically anchored in the

    treatment models of the different schools of psychother-apy, nor are they considered in the treatment models forspecic mental disorders. The concept can be traced backto Saul Rosenzweigs (1936) implicit factors shared bydifferent methods of psychotherapy, such as the relation-ship between patient and therapist. In the 1960s, JeromeFrank (1971) developed his Common Component Modeladvocating four common factors: a conding relationship;a socially sanctioned institutional context; a therapeuticrationale (myth) offering an explanation of a patientsproblems; and particular tasks and procedures to solvethese problems (rituals). Subsequently, a series of authorshave proposed further sets of common factors, such asaffective experiencing, cognitive mastery and behaviouralregulation (Karasu, 1986); problem confrontation, correctiveemotional experience (Weinberger, 1995); resource activa-tion, clarication and coping (Grawe, 1995).The controversy between specic and common factors

    (. . .) has pervaded several decades and is still the guidinginuence that directs the reections in the eld aboutfactors responsible for change (Castonguay & Beutler,2006, p. 632). It is becoming increasingly evident, how-ever, that this horse race of determining the mostrelevant change principle assumes a dichotomy of spe-cic and common factors that is based on terminologicaland conceptual inconsistencies, has little empirical valid-ity and fails to do justice to the complexity of the thera-peutic change process.Especially how the term common factor is currently

    being used is confusing (Lampropoulos, 2000): the literatureshows great inconsistency as to which levels of the GenericModel of Psychotherapy (Orlinsky et al., 2004) commonfactors refer to. Specic factors, however, solely refer tothe technical aspect of the therapeutic process, i.e. theyare identical to psychotherapeutic techniques. In otherwords, common and specic factors address differentaspects and levels of the psychotherapeutic process(Pfammatter & Tschacher, 2012). It is therefore inadequateto contrast common factors with specic factors becausethese concepts reside at incommensurate logical levels.Rather than competing in a horse race against eachother, specic factors, i.e. techniques, and commonfactors should be viewed by their interaction (Karasu,1986; Goldfried, 1980; Butler & Strupp, 1986).

    In addition, a dichotomy of common versus specicfactors has not received empirical support. For both,signicant relations to outcome have been shown: A seriesof meta-analyses demonstrated that several aspects of thecommon factor therapeutic alliance, such as empathy orgoal consensus, are clearly related to positive outcome(Lambert & Cattani, 2012; Norcross & Wampold, 2011a).At the same time, also techniques such as exposure,empty-chair technique, paradoxical intention and particu-lar forms of interpretations were (. . .) found to be consist-ently and strongly associated with positive therapeuticoutcome (Orlinsky et al., 2004, p. 341). Thus, the questionis less which of both, techniques or common factors, aremore important but how each relate to the other so thatthey can be successfully tailored to a specic patient(Norcross & Wampold, 2011b).Clear terminology and accurate conception of process

    variables is of paramount importance in this context. Cur-rently, several projects aim at creating a common languagefor techniques, such as the development of a Comprehen-sive Psychotherapeutic Interventions Rating Scale byTrijsburg et al. (2002), the Multitheoretical List of Thera-peutic Interventions by McCarthy and Barber (2008) andthe web-based project Common Language for Psychother-apy byMarks (2010). The Taxonomy Project presented hereis an attempt to empirically arrive at a more preciselanguage for, and conception of, common factors in psycho-therapy. The Taxonomy Project deviates from the either-ormentality prominent in the camp of school-specic anddisorder-specic factors (medical model) and the campof the proponents of common factors (contextual model;Wampold et al., 2001). Rather than mutually exclusivecauses of change, we consider specic techniques and com-mon factors as associated components of psychotherapyprocess.For the present study, we decided to analyze the

    relationships between specic techniques and commonfactors through the use of expert opinion. We collectedassessments of psychotherapy experts in the frameworkof an extensive survey, to which researchers of psycho-therapy were invited. Techniques were treated as givenanchor points (i.e. as independent variables) because tech-niques are operationalized and dened in the manualsand textbooks of different psychotherapy schools. In otherwords, we used techniques as the entities that allowdescribing the dependent variables in our study: thecommon factors of psychotherapy. Doing this, the goalof the Taxonomy Project was to contribute to a clearerdenition and conception of common factors. Thereby, wealso wished to introduce a novel understanding of speci-city in the common versus specic debate: common factorsmay be considered specic insofar as they may be gener-ated by specic subsets of techniques and possibly inhibitedby other subsets of techniques. We hypothesized thatcommon factors would markedly differ with respect to

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  • their relations to specic techniques. This would thenallow a precise operational denition of each commonfactor: a common factor is that which is implemented bya specic pattern of techniques. Therefore, the primarygoal of this study was the description of all commonfactors by their idiosyncratic associations with techniques.In this, we relied on the consensual knowledge of psycho-therapy experts acting as referees who assessed theseassociations step by step. Accordingly, we hypothesized insecond line that rater variables (gender, age, profession,allegiance to a psychotherapy approach) would inuencethe assessments to a limited degree only.

    METHODS

    Selection of Common Factors and Specic Techniques

    A recent comprehensive literature search identied allconstructs discussed as non-specic or common factors oftherapeutic change in psychotherapy research literature.Pfammatter and Tschacher (2012) included all factors thatwere described by at least two authors. For the presentstudy, we adopted this list of 22 common factors, whichare dened in Table 1.Simultaneously, based on textbooks of the four major

    approaches of psychotherapy (cognitive behavioural ther-apy, psychodynamic therapy, humanistic therapy andsystemic therapy), we selected 22 standard techniques(Table 2) of these approaches (numbers of factors andtechniques are equal by coincidence). Our selection oftechniques was subjective. We selected techniques thatrepresent the most characteristic procedures of the majorpsychotherapy approaches, particularly those techniquesthat a group of experienced psychotherapy researcherswould supposedly be familiar with, even if a techniqueoriginated from a different psychotherapy approach thanthe researchers own.

    Survey

    An internet-based survey consisting of the 22 commonfactors and 22 specic techniques was developed. Afterlogging into the system, a participant was briefed on theobjectives of the study: to investigate the relationshipbetween techniques and common factors, with the ultimategoal of arriving at a taxonomy of common factors. Onthe next page, as an initial common factor, TherapeuticAlliance1 was introduced and dened (Table 1). Theinstruction was: Please assess how much, in your opinion,

    this common factor is implemented by each of the followingstandard techniques, and the participant was presented thelist of 22 psychotherapy techniques. Adjacent to each of thelisted techniques, a brief description of the technique wasprinted, e.g.: Positive reinforcement technique: the therapistcommends and rewards desirable behaviour of the patient.For each technique, a 5-point Likert scale (not, little, moder-ate, marked, strong) was provided to record the partici-pants response. We assigned the values 2, 1, 0, 1, 2 tothe points of the scales. The list of techniques was presentedinxed sequence in the order of Table 2. This procedurewasrepeated on new pages until all common factors had beenpresented to the participant, or until the participantstopped the survey. The point of stopping was book-marked so that it was possible to resume the survey at alater time. A complete survey lasted approximately50min and contained 22 22 = 484 items per participant.

    Participants

    Experienced researchers of psychotherapy, most of whomwere also active psychotherapists, were contacted viapersonal e-mails and invited to participate as expert ratersin an internet-based survey (using the platform Survey-Monkey). We contacted, in rst line, German-speakingmembers of the Society for Psychotherapy Research, andin second line, further psychotherapy researchers with apsychiatric afliation. Most addressees had an academicbackground. Of 140 researchers addressed, 68 nallyparticipated in the survey (mean age 50.2years, standarddeviation (SD)=11.1; 47 (69%) men). Non-responders didnot signicantly differ from participants with respect togender, yet mean age of non-responders was higher:54.6years; t(138) = 2.47, p< 0.05. Participants mean profes-sional experience in psychotherapy research (independentvariable Experience) was 18years (SD=11.0), and currentactive psychotherapeutic work was 9h/week (SD=8.8).As for their professional and scientic backgrounds (inde-pendent variable Profession), 54 participants (79.4%) werepsychologists, nine (13.2%) were psychiatrists, four (5.9%)were both psychologists and psychiatrists and one (1.5%)was trained in another profession. Professions of non-responders were not signicantly different (chi2(3) = 2.37,p=0.50). Participants (variable Rater) noted their predom-inant psychotherapeutic orientations (independent variableAllegiance) as cognitivebehavioural (n=29, 42.6%),psychodynamic (n=19, 27.9%), eclectic (n=14, 20.6%),systemic (n=4, 5.9%) and client-centred (n=2, 2.9%).

    Statistical Procedures

    Each participating rater assessed the associations between22 techniques and 22 common factors, i.e. he or sheresponded to a maximum of 22 22 = 484 items. With

    1In the following text, common factors will be printed bold, tech-niques in italics

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    Copyright 2012 John Wiley & Sons, Ltd. Clin. Psychol. Psychother. 21, 8296 (2014)

  • Table 1. List of common factors with denition given in the survey; Relevance, intercepts of all ratings of a common factor (test againstzero: * p< 0.05; ** p< 0.01; *** p< 0.001; **** p< 0.0001); Explanation, % variance of a common factor explained by all techniques (cf. text)

    Common factor Denition Relevance Explanation

    Therapeutic alliance Patient and therapist establish a trusting, cooperative relationship;characterized on the therapist side by afrmation and affectivewarmth towards the patient as a person (interactional variables ofRogers, 1951). Alliance includes mutual connectedness and consensusabout therapeutic goals and tasks (see Bordins (1979) concept ofworking alliance)

    0.17* 16.90

    Mitigation of socialisolation

    Patient experiences a reduction of social isolation and alienation(according to Lambert & Ogles, 2004)

    0.26** 24.72

    Provision of anexplanatory scheme

    Patient is offered a theoretical scheme which provides a plausibleexplanation of her or his problems and which prescribes aprocedure (ritual) for the resolution of problems (see the commonfactor credible rationale (myth) by Frank, 1971)

    0.03 22.04

    Instillation of hope Patient forms the expectation that the therapy will succeed and her orhis problems will be improving (refers to the common factorsinstillation of hope by Frank (1971) and induction of positivechange expectations by Grawe, 2004)

    0.05 24.39

    Readiness to change Patient develops the readiness to change her or his situation orbehaviour (refers to the common factors persuasion to change byTracey et al. (2003) and encouragement to try new behaviours byLambert & Ogles, 2004)

    0.04 19.91

    Patient engagement Patient actively participates, is engaged in the therapeutic process(see common factors client active participation by Lambert &Ogles (2004) and patient role engagement of the Generic Model ofPsychotherapy, Orlinsky et al., 2004)

    0.22** 23.71

    Resource activation Therapist emphasizes and vitalizes strengths, abilities and resourcesof the patient (see the common factor resource activation by Grawe,2004)

    0.04 27.90

    Affective experiencing Patient experiences emotions and affects that are associated with her orhis problems (see common factor affective experiencing by Karasu,1986)

    0.17* 29.81

    Affective catharsis Patient expresses yet repressed feelings (refers to the psychoanalyticcatharsis thesis)

    0.14 29.44

    Problemconfrontation

    Patient is encouraged to face, experience and deal with her or hisproblems (see the common factors encouragement to faceproblematic issues by Weinberger (1995) and problem actualizationby Grawe, 2004)

    0.14* 35.75

    Desensitization Patient experiences progressing attenuation of emotional reactions toaversive stimuli (see the common factors desensitization andextinction of anxiety-associated responses by Lambert & Ogles,2004)

    0.39**** 25.98

    Corrective emotionalexperience

    Patient learns that the real experiences in problematic situations arenot as devastating as the imagined or feared consequences (see thechange factor corrective emotional experience originallyconceptualized by Alexander (1950) in the context ofpsychodynamic therapies)

    0.10 20.98

    Mindfulness Patient develops the ability of nonjudgmental awareness of her or histhoughts, perceptions and feelings. She or he learns to be aware ofinner processes in the here and now without judging them (refersto the Buddhist attitude of an evenminded-accepting attention toall sensations, emotions and thoughts)

    0.43**** 17.00

    Emotion regulation Patient learns to perceive, express and control her or his emotionsmore adequately (refers to affect regulation, according to Fonagyet al. (2002) the process by which individuals inuence whichemotions they have, when they have them and how theyexperience and express these emotions)

    0.15* 22.75

    (Continues)

    85Taxonomy of Common Factors in Psychotherapy

    Copyright 2012 John Wiley & Sons, Ltd. Clin. Psychol. Psychother. 21, 8296 (2014)

  • common factor as dependent variable and a sample of 68raters, the dataset available for each common factor com-prised a maximum of 22 68 = 1496 records. The inter-net-based survey, however, did not enforce completedatasets, thus the actual number of responses receivedfor a common factor ranged between 920 and 1338 records(see the row Observations (n) in Table 3). In other words,dependent variables had varying missing information inthe predicting variables. Because of the expected missingdata and in order to account for statistically dependentdata (each rater performed repeated assessments), weapplied mixed-effects hierarchical analyses to model thedependent variables (i.e. the common factors) by theindependent variables (i.e. the techniques and ratersdemographic variables). The software package used inall analyses was JMP 9 (SAS Institute Inc., Cary, NC). Adataset of 22 techniques 68 raters was thus available

    for each common factor and served as the basis for allsubsequent analyses in approaches a and b.Approach a: in an initial modelling approach, we

    described each common factor by dening two separatedimensions, Relevance and Explanation (Table 1). Thesedimensionswere operationalized as follows: The dimensionRelevance was computed, in each common factor as thedependent variable, by the intercept of a model with onlythe variable Rater entered as a random effect (approach a.1).The single ratings constituted level 1, Rater identiedlevel 2 of the data. The intercepts operationalize the overallrelevance of a common factor. These intercepts were verysimilar in value to the mean of response (r=0.99), i.e. themean of all single ratings a common factor received (ratingsranging between 2 and 2). In the column Relevance ofTable 1,we listed these intercepts. The interceptswere testedagainst zero, the midpoint of the scales.

    Table 0. (Continued)

    Common factor Denition Relevance Explanation

    Insight Patient develops awareness of her or his problems and a conception oftheir causal relation and their relation with recurring patterns of her orhis behaviour (see the common factors foster insight/awareness byGrencavage & Norcross (1990) and motivational clarication byGrawe, 2004)

    0.03 31.51

    Assimilatingproblematicexperiences

    Patient approximates problematic experiences to pre-existing owncognitive schemata and is thereby able to be more familiar withthem (refers to the distinction introduced by Piaget betweenAssimilation and Accommodation as to two different types ofdeveloping and changing cognitive representations of the world)

    0.22** 20.64

    Cognitiverestructuring

    Patient gradually accommodates conceptualizations of problems,acquires new perceptions and thinking patterns, which promoteunderstanding and integration of problematic experiences (seecommon factor cognitive mastery, Karasu, 1986)

    0.16 26.78

    Mentalization Patient learns to understand herself or himself and others in terms ofmental states (i.e. feelings, thoughts, intentions) and therebydevelops the ability of anticipating the behaviours and reactions ofothers (theory of mind) (see the capacity to read, (. . .) predict andexplain other peoples actions by inferring and attributing causalintentional mind states to them (Fonagy et al., 2002))

    0.24** 31.25

    Behaviour regulation Patient learns new behavioural responses and social skills to modifyhabits and to manage and control actions (see the common factorsbehavioural regulation by Karasu (1986) and learning of masterybehaviours by Lambert & Ogles, 2004)

    0.24** 35.12

    Mastery experiences Patient gathers successful coping experiences (see the commonfactors mastery efforts and success experience by Lambert &Ogles (2004) and coping by Grawe, 2004)

    0.25** 33.25

    Self-efcacyexpectation

    Patient increases her or his sense of personal inuence and control(see the common factor changing expectations of personaleffectiveness by Lambert & Ogles (2004), derived from Bandurasconceptualization of self-efcacy)

    0.22** 34.27

    New narrative aboutself

    Patient develops a new sense of coherence regarding her or his past,present and future life, as well as her or his being in the world (seethe common factor construction of a meaning-generatingnarrative by Jorgensen, 2004)

    0.21** 25.64

    Table 1. (Continued)

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    Copyright 2012 John Wiley & Sons, Ltd. Clin. Psychol. Psychother. 21, 8296 (2014)

  • As a second dimension, we assessed Explanation. Wecomputed models with Rater entered as a random effectand Technique as the xed effect (approach a.2). Thecorresponding explained variances operationalize thedegree of differential explanation of each common factorby the set of techniques. Finally, to integrate the two

    dimensions of approach a, the ratio Relevance/Explanationwas computed which is positive if both Relevance and Ex-planation assume positive values.Approach b addressed the primary goal of the study by

    comprehensive modelling including the inuence of ratercharacteristics. We modelled each of the 22 common factors

    Table 2. List of techniques with denition given in the survey

    Technique Denition

    Positive reinforcement technique Therapist praises/rewards desired, adequate patient behaviour.Exposure with response prevention Therapist confronts patient in imagination or in vivo, gradually or by ooding,

    massed or in intervals with a problematic situation and prevents escape.Role play technique Therapist simulates difcult social interactions in a play with patient as

    participant, and instructs, models and corrects the performance.Problem-solving training Therapist teaches patient to identify and dene the problem, to systematically

    generate and evaluate alternative problem solutions, to implement and verifyselected problem solution.

    Reality testing Therapist encourages patient to test the evidence for the validity ofdysfunctional thoughts and beliefs, runs behavioural experiments andprovides alternative explanations.

    Free association technique Therapist encourages patient to talk about whatever comes to her or his mind.Therapeutic abstinence Therapist deliberately does not comment statements, disclosures or behaviour

    of patient.Transference interpretation Therapist links patienttherapist relationship to other interactions of patient to

    point out recurring problematic themes in her or his relationships.Resistance interpretation Therapist draws attention to the patients opposition to or avoidance of certain

    topics, experiences or feelings by pointing out evasions, sudden thematic shiftsor behavioural inconsistencies.

    Verbalization of emotionalreactions

    Therapist listens carefully to what patient is saying, uses empathic statements,repeats back (paraphrases), explores its personal meaning and reects theinternal frame of reference (mirroring).

    Focusing Therapist draws attention to unexpressed feelings, promotes deeperexperiencing, encourages patient to explore and express feelings.

    Empty-chair and two-chairtechnique

    Therapist guides patient to speak to an empty chair for unnished business, orengages patient in a two-chair dialogue for analyzing and resolving innerconicts.

    Creative expression technique Therapist encourages patient to use creative media to actualize experiences andexpress feelings.

    Circular questions technique Therapist explores the meaning of a problematic behaviour of a family memberfor another family member with a third family member.

    Sculpture work Therapist asks the family to spatially illustrate the familial relationships(afnity, distance, hierarchical structure) by building a sculpture.

    Paradoxical intention technique Therapist offers a new interpretative framework (reframing), assigns a positivemeaning to the problem (positive connotation), invites patient to deliberatelyshow the problem behaviour (symptom prescription) or offers lots of problemsolutions (confusion technique).

    Prescription of rituals Therapist prescribes formalized and symbolic actions that disrupt problematicbehaviour.

    Reecting team technique A team of experts monitors therapy and discusses the observations withparticipants.

    Progressive muscle relaxation Therapist guides patient to rhythmically and sequentially contract and relaxdifferent groups of muscles.

    Hypnosis Therapist asks patient to bring up pictures or scenes, or induces hypnotic tranceby verbal suggestions and motoric procedures.

    Biofeedback training Therapist guides patient to deliberately inuence and control physiologicalprocesses by feedback signals, discriminative learning and relaxation techniques.

    Counselling Therapist gives advice.

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    Copyright 2012 John Wiley & Sons, Ltd. Clin. Psychol. Psychother. 21, 8296 (2014)

  • Table3.

    ad.R

    esultsof

    mixed-effectsmod

    ellin

    gof

    each

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    factor.C

    ommon

    factor,d

    ependentvariable;techn

    iquesandratercharacteristics,xedeffects:*p