I have been thinking about and writing about the common factors and their operationalization for many years. Research continues to build a compelling case for the presence of pantheoretical factors in operation that overshadow any perceived or presumed differences among approaches. For example, our alliance article soon to be published in the Journal of Consulting and Clincal Psychology found the alliance to be predictive of outcome over and above early treatment change and our in preparation investigation of therapist effects found that differences among therapists were best explained by their alliance abilities–over gender, discipline, or experience (more on both of these studies later). Some of you may have seen my depiction of the factors shown below:

I am always striving to describe the factors in a way that illustrates their interdependence. Here is my latest effort: Five factors comprise this perspective: client, therapist, alliance, the model/technique delivered, and feedback—all interdependent and overlapping. Technique is the alliance in action, carrying an explanation for the client’s difficulties and a remedy for them—an expression of the therapist’s belief that it could be helpful in hopes of engendering the same response in the client. Indeed, you cannot have an alliance without a treatment, an agreement between the client and therapist about how therapy will address the client’s goals. Similarly, you cannot have a positive expectation for change without a credible way for both the client and therapist to understand how change can happen. And the only way to know whether the common factors are in operation is to obtain real time client feedback about the benefit and fit of services. Feedback overlaps with and affects all the factors—it is the tie that binds them together—allowing the common factors to be delivered one client at a time. Soliciting systematic feedback is a living, ongoing process that engages clients in the collaborative monitoring of outcome, heightens hope for improvement, fits client preferences, maximizes therapist-client fit, and is itself a core feature of therapeutic change.

And I believe the only way to fully understand the importance of the common factors, including feedback, is to see them in action with real clients. Consequently, a new feature has been added to CDOI Members: actual client videos (client idenities are protected) are now available to Members for anytime viewing and learning.

Also, please check out the free webinars about my new book, On Becomng a Better Therapist. They are posted as they occur on the Video page, and the pdf of the slides as well as the videos are posted on the discussion page.

Finally, check out the following video made by Robyn Pope, a certified CDOI trainer of the Heart and Soul of Change Project, of staff at Wesley Community Action.  Wesley is a broad based social service agency that provides culturally sensitive and socially just services in non traditional settings. Robyn solicits staff reactions about the use of the Outcome Rating Scale and Session Rating Scale, including how they have grown professionally and personally as well as the challenges they have faced in implementation.

One of the great controversies in psychotherapy has been the common v. specific factors debate. On one hand, the common factors, or the notion that it is the pantheoretical aspects of providing psychotherapy, those elements common to all (like the alliance) that account for change. On the other hand, the specific factors side argues that there are unique ingredients to particular models of practice that explain how people change in therapy. The common factors side of things enjoys far more empirical support given that no approach has every shown superiority over another, have not ever demonstrated the proposed specific effects, and model differences only account for 1% of the overall variance. It would be great, however, to move beyond the common v specific factors polemics because of course, the factors are intimately intertwined in all ways imaginable. But it is tough when various orientations continue to argue for specific factors in somewhat deceptive attempts to privilege different models. Fact of the matter is you can’t really separate the specific elements of a given model from the context it occurs in (not to mention who is delivering the treatment), or the general effects of delivering any treatment.

Here is how I am writing about the interdependence (excerpted from my new book, On Becoming a Better Therapist): The specific factors (the differences between models) have a relatively small impact but the general effects of delivering a treatment are far more potent. As Jerome Frank (1973) seminally noted, all models include a rationale or myth, an explanation for the client’s difficulties, and a procedure or ritual, strategies to follow for resolving them. Models achieve their effects, in large part, if not completely through the activation of placebo, hope, and expectancy, combined with the therapist’s belief in (allegiance to) the treatment administered. As long as a treatment makes sense to, is accepted by, and fosters the active engagement of the client, the particular approach used is unimportant. Said another way, therapeutic techniques are placebo-delivery devices (Kirsch, 2005).

Allegiance and expectancy are two sides of the same coin—the belief by both the therapist and the client in the restorative power and credibility of the therapy’s rationale and related rituals. When a placebo or technically “inert” condition is offered in a manner that fosters positive expectations for improvement, it reliably produces effects almost as large as a bona fide treatment (Baskin, Tierney, Minami, & Wampold, 2003). The TDCRP is again instructive. First, across all conditions, client expectation of improvement predicted outcome (Sotsky et al., 1991). And second, an inspection of the Beck Depression Inventory scores of those who completed the study (see Elkin et al., 1989) reveals that the placebo plus clinical management condition accounted for nearly 93% of the average response to the active treatments. The act of administering treatment—the model/technique delivered—is the vehicle that carries allegiance and placebo effects in addition to the specific effects of the given approach.

It pays, therefore, to have several rationales and remedies at your disposal that you believe in, as well as believing in the possibility of the client’s ideas about change. Finally, it is important to note that suggesting specific effects are small in comparison to general effects, and that psychotherapy approaches achieve about the same results does not mean that models and techniques are not important. On the contrary, a particular orientation or method may be just the ticket for a given client—while there is no differential efficacy on aggregate, there are approaches that are likely better or worse for the client in your office now.
Bottom Line: The specifics of any approach, either unique to the client or of a particular orientation, are not as important as the cogency of the rationale and ritual to both the client and the therapist, and most importantly, the client’s response to the delivered treatment.

And then there is the alliance context of delivering any specific treatment. The alliance is an all-encompassing framework for psychotherapy—it transcends any specific therapist behavior and is a property of all aspects of providing services (Hatcher & Barends, 2006). The alliance is evident in anything and everything you do—from offering an explanation or technique to address the client’s situation to scheduling the next appointment—to engage the client in purposive work. In an important way, the alliance is dependent on the delivery of some particular treatment—a framework for understanding and solving the problem. The alliance cannot happen without technique (Hatcher & Barends, 2006). If technique fails to engage the client in purposive work, it is not working properly and a change is needed. Think of it this way: Technique is an activity—the alliance is a way to characterize that activity; the alliance is the purpose of the activity (Hatcher & Barends, 2006). Although it is possible for a strong relationship to develop between you and the client, there can be no agreement about the tasks of therapy, a critical aspect of the alliance, without some discussion and negotiation of what “treatment” will be used (Wampold, 2010)—be it some specific approach, the client’s own ideas and cultural preferences, or some unique blend.

The overlapping components of the Venn diagram below depicts the interdependent common factors. There can be no alliance without a treatment, and on the other hand, technique is only as effective as its delivery system—the client-therapist relationship. So you can’t have a good alliance without some agreement about how therapy is going to address the issues at hand. You can’t have purposeful work without collaboration about what that work will entail.

Here is where the incredible variety of models and techniques pays off. While there is no differential efficacy among approaches in general, there is differential efficacy among approaches with the client in your office now. The question is: does it resonate or not? Does it fit client preferences? Does its application help or hinder the alliance? Is it something that both you and the client can get behind? You matter here too. If you don’t believe in the potential restorative or healing power of any selected approach—i.e., don’t have allegiance to it—then not much good will come of it. Can you get on board with the client’s notions about how he or she can be helped? Or perhaps some idiosyncratic blend of client ideas, yours, and theoretical/technical ones might ultimately be just the ticket. Your alliance skills are truly at play here: your interpersonal ability to explore the client’s ideas, discuss options, collaboratively form a plan, and negotiate any changes when benefit to the client is not forthcoming. Technique, its selection and application, in other words, are instances of the alliance in action.

So it doesn’t make a whole lot of sense to think of things separately. That is what my hallucinogenic figure tries to portray. BTW, see a full explanation of the common factors diagram on the handouts page:
http://heartandsoulofchange.com/resources/handouts/

And don’t forget to register for the free webinar!

Title: “Dr. Barry Duncan– What in the heck is CDOI? Client Directed, Outcome Informed Ideas and Practices
Date: Tuesday, December 22, 2009
Time: 12:00 PM – 1:00 PM CDT
Register now by clicking the link below:
https://www2.gotomeeting.com/register/326593746

Here are the slides:

Coming soon: People have asked me about my Oprah appearance for years. On my next blog, I will post the video. The deal is that I am posting it but you are not allowed to laugh about it, at least not to my face!