Common factors theory, a theory guiding some research in clinical psychology and counseling psychology, proposes that different approaches and evidence-based practices in psychotherapy and counseling share common factors that account for much of the effectiveness of a psychological treatment.This is in contrast to the view that the effectiveness of psychotherapy and counseling is best explained by specific or unique factors (notably, particular methods or procedures) that are suited to treatment of particular problems. According to one review, "it is widely recognized that the debate between common and unique factors in psychotherapy represents a false dichotomy, and these factors must be integrated to maximize effectiveness". In other words, "therapists must engage in specific forms of therapy for common factors to have a medium through which to operate". Common factors is one route by which psychotherapy researchers have attempted to integrate psychotherapies.
Saul Rosenzweig started the conversation on common factors in an article published in 1936 that discussed some psychotherapies of his time.John Dollard and Neal E. Miller's 1950 book Personality and Psychotherapy emphasized that the psychological principles and social conditions of learning are the most important common factors. Sol Garfield (who would later go on to edit many editions of the Handbook of Psychotherapy and Behavior Change with Allen Bergin) included a 10-page discussion of common factors in his 1957 textbook Introductory Clinical Psychology.
In the same year, Carl Rogers published a paper outlining what he considered to be common factors (which he called "necessary and sufficient conditions") of successful therapeutic personality change, emphasizing the therapeutic relationship factors which would become central to the theory of person-centered therapy.He proposed the following conditions necessary for therapeutic change: psychological contact between the therapist and client, incongruence in the client, genuineness in the therapist, unconditional positive regard and empathic understanding from the therapist, and the client's perception of the therapist's unconditional positive regard and empathic understanding.
In 1961, Jerome Frank published Persuasion and Healing, a book entirely devoted to examining the common factors among psychotherapies and related healing approaches.Frank emphasized the importance of the expectation of help (a component of the placebo effect), the therapeutic relationship, a rationale or conceptual scheme that explains the given symptoms and prescribes a given ritual or procedure for resolving them, and the active participation of both patient and therapist in carrying out that ritual or procedure.
After Lester Luborsky and colleagues published a literature review of empirical studies of psychotherapy outcomes in 1975,the idea that all psychotherapies are effective became known as the Dodo bird verdict, referring to a scene from Alice's Adventures in Wonderland quoted by Rosenzweig in his 1936 article; in that scene, after the characters race and everyone wins, the Dodo bird says, "everybody has won, and all must have prizes." Luborsky's research was an attempt (and not the first attempt, nor the last one) to disprove Hans Eysenck's 1952 study on the efficacy of psychotherapy; Eysenck found that psychotherapy generally did not seem to lead to improved patient outcomes. A number of studies after 1975 presented more evidence in support of the general efficacy of psychotherapy, but the question of how common and specific factors could enhance or thwart therapy effectiveness in particular cases continued to fuel theoretical and empirical research over the following decades.
The landmark 1982 book Converging Themes in Psychotherapy gathered a number of chapters by different authors promoting common factors, including an introduction by Marvin R. Goldfried and Wendy Padawer, a reprint of Rosenzweig's 1936 article, and further chapters (some of them reprints) by John Dollard and Neal E. Miller, Franz Alexander, Jerome Frank, Arnold Lazarus, Hans Herrman Strupp, Sol Garfield, John Paul Brady, Judd Marmor, Paul L. Wachtel, Abraham Maslow, Arnold P. Goldstein, Anthony Ryle, and others.The chapter by Goldfried and Padawer distinguished between three levels of intervention in therapy:
Goldfried and Padawer argued that while therapists may talk about their theories using very different jargon, there is more commonality among skilled therapists at the (intermediate) level of principles or strategies. Goldfried and Padawer's emphasis on principles or strategies of change was an important contribution to common factors theory because they clearly showed how principles or strategies can be considered common factors (they are shared by therapists who may espouse different theories of change) and specific factors (they are manifested in particular ways within different approaches) at the same time.Around the same time, James O. Prochaska and colleagues, who were developing the transtheoretical model of change, proposed ten "processes of change" that categorized "multiple techniques, methods, and interventions traditionally associated with disparate theoretical orientations," and they stated that their processes of change corresponded to Goldfried and Padawer's level of common principles of change.
In 1986, David Orlinsky and Kenneth Howard presented their generic model of psychotherapy, which proposed that five process variables are active in any psychotherapy: the therapeutic contract, therapeutic interventions, the therapeutic bond between therapist and patient, the patient's and therapist's states of self-relatedness, and therapeutic realization.
In 1990, Lisa Grencavage and John C. Norcross reviewed accounts of common factors in 50 publications, with 89 common factors in all, from which Grencavage and Norcross selected the 35 most common factors and grouped them into five areas: client characteristics, therapist qualities, change processes, treatment structure, and therapeutic relationship.In the same year, Larry E. Beutler and colleagues published their systematic treatment selection model, which attempted to integrate common and specific factors into a single model that therapists could use to guide treatment, considering variables of patient dimensions, environments, settings, therapist dimensions, and treatment types. Beutler and colleagues would later describe their approach as "identifying common and differential principles of change".
In 1992, Michael J. Lambert summarized psychotherapy outcome research and grouped the factors of successful therapy into four areas, ordered by hypothesized percent of change in clients as a function of therapeutic factors: first, extratherapeutic change (40%), those factors that are qualities of the client or qualities of his or her environment and that aid in recovery regardless of his or her participation in therapy; second, common factors (30%) that are found in a variety of therapy approaches, such as empathy and the therapeutic relationship; third, expectancy (15%), the portion of improvement that results from the client's expectation of help or belief in the rationale or effectiveness of therapy; fourth, techniques (15%), those factors unique to specific therapies and tailored to treatment of specific problems.Lambert's research later inspired a book on common factors theory in the practice of therapy titled The Heart and Soul of Change.
In the mid-1990s, as managed care in mental health services became more widespread in the United States, more researchers began to investigate the efficacy of psychotherapy in terms of empirically supported treatments (ESTs) for particular problems, emphasizing randomized controlled trials as the gold standard of empirical support for a treatment.In 1995, the American Psychological Association's Division 12 (clinical psychology) formed a task force that developed lists of empirically supported treatments for particular problems such as agoraphobia, blood-injection-injury type phobia, generalized anxiety disorder, obsessive–compulsive disorder, panic disorder, etc. In 2001, Bruce Wampold published The Great Psychotherapy Debate, a book that criticized what he considered to be an overemphasis on ESTs for particular problems, and he called for continued research in common factors theory.
In the 2000s, more research began to be published on common factors in couples therapy and family therapy.
In 2014, a series of ten articles on common factors theory was published in the APA journal Psychotherapy .The articles emphasized the compatibility between ESTs and common factors theory, highlighted the importance of multiple variables in psychotherapy effectiveness, called for more empirical research on common factors (especially client and therapist variables), and argued that individual therapists can do much to improve the quality of therapy by rigorously using feedback measures (during treatment) and outcome measures (after termination of treatment). The article by Stefan G. Hofmann and David H. Barlow, two prominent researchers in cognitive behavioral therapy, pointed out how their recent shift in emphasis from distinct procedures for different diagnoses to a transdiagnostic approach was increasingly similar to common factors theory.
There are many models of common factors in successful psychotherapy process and outcome.Already in 1990, Grencavage and Norcross identified 89 common factors in a literature review, which showed the diversity of models of common factors. To be useful for purposes of psychotherapy practice and training, most models reduce the number of common factors to a handful, typically around five. Frank listed six common factors in 1971 and explained their interaction. Goldfried and Padawer listed five common strategies or principles in 1982: corrective experiences and new behaviors, feedback from the therapist to the client promoting new understanding in the client, expectation that psychotherapy will be helpful, establishment of the desired therapeutic relationship, and ongoing reality testing by the client. Grencavage and Norcross grouped common factors into five areas in 1990. Lambert formulated four groups of therapeutic factors in 1992. Joel Weinberger and Cristina Rasco listed five common factors in 2007 and reviewed the empirical support for each factor: the therapeutic relationship, expectations of treatment effectiveness, confronting or facing the problem (exposure), mastery or control experiences, and patients' attributions of successful outcome to internal or external causes.
Terence Tracy and colleagues modified the common factors of Grencavage and Norcross, and used them to develop a questionnaire which they provided to 16 board certified psychologists and 5 experienced psychotherapy researchers; then they analyzed the responses and published the results in 2003.Their multidimensional scaling analysis represented the results on a two-dimensional graph, with one dimension representing hot processing versus cool processing (roughly, closeness and emotional experience versus technical information and persuasion) and the other dimension representing therapeutic activity. Their cluster analysis represented the results as three clusters: the first related to bond (roughly, therapeutic alliance), the second related to information (roughly, the meanings communicated between therapist and client), and the third related to role (roughly, a logical structure so that clients can make sense of the therapy process).
In addition to these models that incorporate multiple common factors, a number of theorists have proposed and investigated single common factors, common principles, and common mechanisms of change, such as learning. In one example, at least three independent groups have converged on the conclusion that a wide variety of different psychotherapies can be integrated via their common ability to trigger the neurobiological mechanism of memory reconsolidation. Further reading, below.For further examples, see §
|Factor||% of Variability|
|Goal consensus / collaboration||11.5%|
|Positive regard / affirmation||7.3%|
|Congruence / genuineness||5.7%|
|Treatment differences||< 1.0%|
While many models of common factors have been proposed, they have not all received the same amount of empirical research. There is general consensus on the importance of a good therapeutic relationship in all forms of psychotherapy and counseling.
A review of common factors research in 2008 suggested that 30% to 70% of the variance in therapy outcome was due to common factors.A summary of research in 2014 suggested that 11.5% of variance in therapy outcome was due to the common factor of goal consensus/collaboration, 9% was due to empathy, 7.5% was due to therapeutic alliance, 6.3% was due to positive regard/affirmation, 5.7% was due to congruence/genuineness, and 5% was due to therapist factors. In contrast, treatment method accounted for roughly 1% of outcome variance.
Alan E. Kazdin has argued that psychotherapy researchers must not only find statistical evidence that certain factors contribute to successful outcomes; they must also be able to formulate evidence-based explanations for how and why those factors contribute to successful outcomes, that is, the mechanisms through which successful psychotherapy leads to change.Common factors theory has been dominated by research on psychotherapy process and outcome variables, and there is a need for further work explaining the mechanisms of psychotherapy common factors in terms of emerging theoretical and empirical research in the neurosciences and social sciences, just as earlier works (such as Dollard and Miller's Personality and Psychotherapy or Frank's Persuasion and Healing ) explained psychotherapy common factors in terms of the sciences of their time.
One frontier for future research on common factors is automated computational analysis of clinical big data.
There are several criticisms of common factors theory, for example:
Some common factors theorists have argued against these criticisms. They state that:
Psychotherapy is the use of psychological methods, particularly when based on regular personal interaction with adults, to help a person change behavior and overcome problems in desired ways. Psychotherapy aims to improve an individual's well-being and mental health, to resolve or mitigate troublesome behaviors, beliefs, compulsions, thoughts, or emotions, and to improve relationships and social skills. There is also a range of psychotherapies designed for children and adolescents, which typically involve play, such as sandplay. Certain psychotherapies are considered evidence-based for treating some diagnosed mental disorders. Others have been criticized as pseudoscience.
Clinical psychology is an integration of science, theory, and clinical knowledge for the purpose of understanding, preventing, and relieving psychologically-based distress or dysfunction and to promote subjective well-being and personal development. Central to its practice are psychological assessment, clinical formulation, and psychotherapy, although clinical psychologists also engage in research, teaching, consultation, forensic testimony, and program development and administration. In many countries, clinical psychology is a regulated mental health profession.
Counseling psychology is a psychological specialty that encompasses research and applied work in several broad domains: counseling process and outcome; supervision and training; career development and counseling; and prevention and health. Some unifying themes among counseling psychologists include a focus on assets and strengths, person–environment interactions, educational and career development, brief interactions, and a focus on intact personalities.
Integrative psychotherapy is the integration of elements from different schools of psychotherapy in the treatment of a client. Integrative psychotherapy may also refer to the psychotherapeutic process of integrating the personality: uniting the "affective, cognitive, behavioral, and physiological systems within a person".
Person-centered therapy, also known as person-centered psychotherapy, person-centered counseling, client-centered therapy and Rogerian psychotherapy, is a form of psychotherapy developed by psychologist Carl Rogers beginning in the 1940s and extending into the 1980s. Person-centered therapy seeks to facilitate a client's self-actualizing tendency, "an inbuilt proclivity toward growth and fulfillment", via acceptance, therapist congruence (genuineness), and empathic understanding.
Cognitive analytic therapy (CAT) is a form of psychological therapy initially developed in the United Kingdom by Anthony Ryle. This time-limited therapy was developed in the context of the UK's National Health Service with the aim of providing effective and affordable psychological treatment which could be realistically provided in a resource constrained public health system. It is distinctive due to its intensive use of reformulation, its integration of cognitive and analytic practice and its collaborative nature, involving the patient very actively in their treatment.
Psychodynamic psychotherapy or psychoanalytic psychotherapy is a form of depth psychology, the primary focus of which is to reveal the unconscious content of a client's psyche in an effort to alleviate psychic tension.
The Dodo bird verdict is a controversial topic in psychotherapy, referring to the claim that all empirically validated psychotherapies, regardless of their specific components, produce equivalent outcomes. It is named after The Dodo character of Alice in Wonderland. The conjecture was introduced by Saul Rosenzweig in 1936, drawing on imagery from Lewis Carroll's novel Alice's Adventures in Wonderland, but only came into prominence with the emergence of new research evidence in the 1970s.
Play therapy is a method of meeting and responding to the mental health needs of children and is extensively acknowledged by experts as an effective and suitable intervention in dealing with children’s brain development. It is generally employed with children aged 3 years through 11 and provides a way for them to express their experiences and feelings through a natural, self-guided, self-healing process. As children's experiences and knowledge are often communicated through play, it becomes an important vehicle for them to know and accept themselves.
Acceptance and commitment therapy is a form of psychotherapy and a branch of clinical behavior analysis. It is an empirically-based psychological intervention that uses acceptance and mindfulness strategies mixed in different ways with commitment and behavior-change strategies, to increase psychological flexibility. The approach was originally called comprehensive distancing. Steven C. Hayes developed acceptance and commitment therapy in 1982 in order to create a mixed approach which integrates both covert conditioning and behavior therapy. There are a variety of protocols for ACT, depending on the target behavior or setting. For example, in behavioral health areas a brief version of ACT is called focused acceptance and commitment therapy (FACT).
The therapeutic relationship refers to the relationship between a healthcare professional and a client. It is the means by which a therapist and a client hope to engage with each other, and effect beneficial change in the client..
Les Greenberg is a Canadian psychologist born in Johannesburg, South Africa, and is one of the originators and primary developers of Emotion-Focused Therapy for individuals and couples. He is a professor emeritus of psychology at York University in Toronto, and also director of the Emotion-Focused Therapy Clinic in Toronto. His research has addressed questions regarding empathy, psychotherapy process, the therapeutic alliance, and emotion in human functioning.
Although modern, scientific psychology is often dated from the 1879 opening of the first psychological clinic by Wilhelm Wundt, attempts to create methods for assessing and treating mental distress existed long before. The earliest recorded approaches were a combination of religious, magical and/or medical perspectives. Early examples of such psychological thinkers included Patañjali, Padmasambhava, Rhazes, Avicenna and Rumi.
Emotionally focused therapy and emotion-focused therapy (EFT) are a family of related approaches to psychotherapy with individuals, couples, or families. EFT approaches include elements of experiential therapy, systemic therapy, and attachment theory. EFT is usually a short-term treatment. EFT approaches are based on the premise that human emotions are connected to human needs, and therefore emotions have an innately adaptive potential that, if activated and worked through, can help people change problematic emotional states and interpersonal relationships. Emotion-focused therapy for individuals was originally known as process-experiential therapy, and it is still sometimes called by that name.
Functional analytic psychotherapy (FAP) is a psychotherapeutic approach based on clinical behavior analysis (CBA) that focuses on the therapeutic relationship as a means to maximize client change. Specifically, FAP suggests that in-session contingent responding to client target behaviors leads to significant therapeutic improvements.
A clinical formulation, also known as case formulation and problem formulation, is a theoretically-based explanation or conceptualisation of the information obtained from a clinical assessment. It offers a hypothesis about the cause and nature of the presenting problems and is considered an adjunct or alternative approach to the more categorical approach of psychiatric diagnosis. In clinical practice, formulations are used to communicate a hypothesis and provide framework for developing the most suitable treatment approach. It is most commonly used by clinical psychologists and psychiatrists and is deemed to be a core component of these professions. Mental health nurses and social workers may also use formulations.
John C. Norcross is an American professor, board-certified clinical psychologist, and author in psychotherapy, behavior change, and self-help.
Psychotherapy discontinuation, also known as unilateral termination, patient dropout, and premature termination, is a patient's decision to stop mental health treatment before they have received an adequate number of sessions. In the United States, the prevalence of patient dropout is estimated to be between 40–60% over the course of treatment however, the overwhelming majority of patients will drop after two sessions. An exhaustive meta-analysis of 146 studies in Western countries showed that the mean dropout rate is 34.8% with a wide range of 10.3% to 81.0%. The studies from the US had a dropout rate of 37.9%.
Accelerated experiential dynamic psychotherapy (AEDP) is a mind-body psychotherapy that is informed by research in the areas of attachment theory, emotion theory, and neuroscience of change. This model of psychotherapy incorporates techniques from experiential therapies and ISTDP.
Eclectic psychotherapy is a form of psychotherapy in which the clinician uses more than one theoretical approach, or multiple sets of techniques, to help with clients' needs. The use of different therapeutic approaches will be based on the effectiveness in resolving the patient's problems, rather than the theory behind each therapy.