1. INFORMATION FROM: DUNCAN, B.L., MILLER, S.D., WAMPOLD, B.E., & HUBBLE, M.A. (EDS). (2010). THE HEART & SOUL OF CHANGE: DELIVERING WHAT WORKS IN THERAPY (2 ND ED.).WASHINGTON, DC: AMERICAN PSYCHOLOGICAL ASSOCIATION. Psychotherapy Integration Unit 2: Common Factors

2. The Research Evidence for Common Factor Models The following PowerPoints from Chapter 2 of the Duncan text will cover: I. A Brief History of Psychotherapy II. Psychotherapy Evidence for Specific Ingredients III. Common Factors IV. Summary & Implications

3. I. A Brief History of Psychotherapy: Two Strands 1. First Strand: Medical Model 2. Second Strand: Common Factors Model

4. 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 treatment 3. The treatment is responsible for the change Freud & Medical Model were challenged by Behaviorists

5. 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 issue 3. Diagnosing current mechanisms that are supporting or maintaining the issue 4. Applying appropriate mechanisms of change (therapy) that disrupts the maintenance of the issue 5. Those appropriate mechanisms of change are responsible for the benefits of therapy

6. 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

7. 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

8. 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

9. 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…

10. 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 effective Confounding variables in research  Researcher’s alliances  Benefits of treatment “controls”  “Supportive counseling” is not treatment as usual

11. 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

12. 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)

13. 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)

14. 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

15. II. Psychotherapy Evidence for Specific Ingredients Three major issues with empirical study in counseling/psychotherapy Psychotherapy 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 factors Structural equivalence can not be studied between a treatment and a non-treatment

16. 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

17. 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

18. 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?

19. 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)

20. 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

21. 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