Common Factors (Wampold)

Wampold, B. E. (2015). How important are the common factors in psychotherapy? An update. World Psychiatry, 14(3), 270-277. (quotes are verbatim)

THE CONTEXTUAL MODEL

The contextual model posits that there are three pathways through which psychotherapy produces benefits. The three pathways of the contextual model involve: a) the real relationship, b) the creation of expectations through explanation of disorder and the treatment involved, and c) the enactment of health promoting actions. Before these pathways can be activated, an initial therapeutic relationship must be established...

The formation of the initial bond is a combination of bottom-up and top-down processing. Humans make very rapid determination (within 100 ms), based on viewing the face of another human, of whether the other person is trustworthy or not (13), suggesting that patients make very rapid judgments about whether they can trust their therapist. More than likely, patients make rapid judgments about the dress of the therapist, the arrangement and decorations of the room (e.g., diplomas on the wall), and other features of the therapeutic setting (14). However, patients come to therapy with expectations about the nature of psychotherapy as well, due to prior experiences, recommendations of intimate or influential others, cultural beliefs, and so forth. The initial interaction between patient and therapist is critical, it seems, because more patients prematurely terminate from therapy after the first session than at any other point (15).

Pathway 1: The real relationship 

The real relationship, defined psychodynamically, is “the personal relationship between therapist and patient marked by the extent to which each is genuine with the other and perceives/experiences the other in ways that befit the other” ((16), p. 119). Although the psychotherapeutic relationship is influenced by general social processes, it is an unusual social relationship in that: a) the interaction is confidential, with some statutory limits (e.g., child abuse reporting), and b) disclosure of difficult material (e.g., of infidelity to a spouse, of shameful affect, and so forth) does not disrupt the social bond. Indeed, in psychotherapy, the patient is able to talk about difficult material without the threat that the therapist will terminate the relationship.

The importance of human connection has been discussed for decades, whether is it called attachment (17), belongingness (18), social support (19), or the lack of loneliness (20,21). In fact, perceived loneliness is a significant risk factor for mortality, equal to or exceeding smoking, obesity, not exercising (for those with chronic cardiac disease or for healthy individuals), environmental pollution, or excessive drinking (22–24). Psychotherapy provides the patient a human connection with an empathic and caring individual, which should be health promoting, especially for patients who have impoverished or chaotic social relations.

Pathway 2: Expectations 

Research in a number of areas documents that expectations have a strong influence on experience (25). Indeed, the purported price of a bottle of wine influences rating of pleasantness as well as neural representations (26). The burgeoning research on the effects of placebos documents the importance of expectations, as placebos have robustly shown to alter reported experience as well as demonstrating physiological and neural mechanisms (27,28).

Expectations in psychotherapy work in several possible ways. Frank (4) discussed how patients present to psychotherapy demoralized not only because of their distress, but also because they have attempted many times and in many ways to overcome their problems, always unsuccessfully. Participating in psychotherapy appears to be a form of remoralization.

However, therapy has more specific effects on expectations than simple remoralization. According to the contextual model, patients come to therapy with an explanation for their distress, formed from their own psychological beliefs, which is sometimes called “folk psychology” (29–31). These beliefs, which are influenced by cultural conceptualizations of mental disorder but also are idiosyncratic, are typically not adaptive, in the sense that they do not allow for solutions. Psychotherapy provides an explanation for the patient’s difficulties that is adaptive, in the sense that it provides a means to overcome or cope with the difficulties. The patient comes to believe that participating in and successfully completing the tasks of therapy, whatever they may be, will be helpful in coping with his or her problems, which then furthers for the patient the expectation that he or she has ability to enact what is needed. The belief that one can do what is necessary to solve his or her problem has been discussed in various ways, including discussions of mastery (4,32), self-efficacy (33), or response expectancies (25).

Critical to the expectation pathway is that patients believe that the explanation provided and the concomitant treatment actions will be remedial for their problems. Consequently, the patient and therapist will need to be in agreement about the goals of therapy as well as the tasks, which are two critical components of the therapeutic alliance (34,35). Hatcher and Barends described the alliance as “the degree to which the therapy dyad is engaged in collaborative, purposive work” ((36), p. 293). Creating expectations in psychotherapy depends on a cogent theoretical explanation, which is provided to the patient and which is accepted by the patient, as well as on therapeutic activities that are consistent with the explanation, and that the patient believes will lead to control over his or her problems. A strong alliance indicates that the patient accepts the treatment and is working together with the therapist, creating confidence in the patient that the treatment will be successful.

Pathway 3: Specific ingredients 

The contextual model stipulates that there exists a treatment, particularly one that the patient finds acceptable and that he or she thinks will be remedial for his or her problems, creating the necessary expectations that the patient will experience less distress. Every treatment that meets the conditions of the contextual model will have specific ingredients, that is, each cogent treatment contains certain well-specified therapeutic actions.

The question is how the specific ingredients work to produce the benefits of psychotherapy. Advocates of specific treatments argue that these ingredients are needed to remediate a particular psychological deficit. The contextual model posits that the specific ingredients not only create expectations (pathway 2), but universally produce some salubrious actions. That is, the therapist induces the patient to enact some healthy actions, whether that may be thinking about the world in less maladaptive ways and relying less on dysfunctional schemas (cognitive-behavioral treatments), improving interpersonal relations (interpersonal psychotherapy and some dynamic therapies), being more accepting of one’s self (self-compassion therapies, acceptance and commitment therapy), expressing difficult emotions (emotion-focused and dynamic therapies), taking the perspective of others (mentalization therapies), and so forth. The effect of lifestyle variables on mental health has been understated (37). A strong alliance is necessary for the third pathway as well as the second, as without a strong collaborative work, particularly agreement about the tasks of therapy, the patient will not likely enact the healthy actions.

According to the contextual model, if the treatment elicits healthy patient actions, it will be effective, whereas proponents of specific ingredients as remedial for psychological deficits predict that some treatments – those with the most potent specific ingredients – will be more effective than others (8)...

EVIDENCE FOR VARIOUS COMMON FACTORS

Alliance 

The alliance is composed of three components: the bond, the agreement about the goals of therapy, and the agreement about the tasks of therapy (12). As discussed above, alliance is a critical common factor, instrumental in both pathway 2 and pathway 3...

Empathy and related constructs 

Empathy, a complex process by which an individual can be affected by and share the emotional state of another, assess the reasons for another’s state, and identify with the other by adopting his or her perspective, is thought to be necessary for the cooperation, goal sharing, and regulation of social interaction. Such capacities are critical to infant and child rearing, as children, who are unable to care for themselves, signal to the caregiver that care is needed, a process that is then put to use to manage social relations among communities of adult individuals. Therapist expressed empathy is a primary common factor, critical to pathway 1 of the contextual model, but which also augments the effect of expectations...

Expectations

Cultural adaptation of evidence-based treatments 

The contextual model emphasizes that the explanation given for the patient’s distress and the therapy actions must be acceptable to the patient. Acceptance is partly a function of consistency of the treatment with the patient’s beliefs, particularly beliefs about the nature of mental illness and how to cope with the effects of the illness. This suggests that evidence-based treatments that are culturally adapted will be more effective for members of the cultural group for which the adapted treatment is designed. There are many ways to adapt treatments, including those involving language, cultural congruence of therapist and patient, cultural rituals, and explanations adapted to the “myth” of the group...

Therapist effects

The contextual model predicts that there will be differences among therapists within a treatment. That is, even though the therapists are delivering the same specific ingredients, some therapists will do so more skillfully and therefore achieve better outcomes than other therapists delivering the same treatment. Evidence for this conjecture is found in clinical trials. A meta-analysis of therapist effects in clinical trials found modest therapist effects (d=0.35, n=29; see Figure 1) (52). Keep in mind that the therapists in clinical trials generally are included because of their competence and then they are given extra training, supervised, and monitored. Moreover, the patients in such trials are homogeneous, as they have a designated diagnosis and are selected based on various inclusionary/exclusionary criteria. In such designs, patients are randomly assigned to therapists. Consequently, consistent differences among therapists in such trials, although modest, are instructive.

Not surprisingly, therapist effects in naturalistic settings are greater than in clinical trials. In the former settings, therapists are more heterogeneous, patients may not be randomly assigned to therapists, patients are heterogeneous, and so forth. A meta-analysis of therapist effects in such settings found a relatively large effect (d=0.55, n=17; see Figure 1) (52). The finding of robust therapist effects raises the question about what are the characteristics or actions of more effective therapists.

Recent research has begun to address this question. Studies have shown that effective therapists (vis-à-vis less effective therapists) are able to form stronger alliances across a range of patients, have a greater level of facilitative interpersonal skills, express more professional self-doubt, and engage in more time outside of the actual therapy practicing various therapy skills (8). [see The Great Psychotherapy Debate: The Evidence for What Makes Psychotherapy Work]

SPECIFIC EFFECTS

Today, there are claims that some treatments, in general or for specific disorders, are more effective than others. Others, however, claim that there are no differences among psychotherapies, in terms of their outcomes.

The literature addressing this issue is immense and summarizing the results of relative efficacy is not possible. Nevertheless, the various meta-analyses for psychotherapies in general or for specific disorders, if they do find differences among various types of treatment, typically find at most differences of approximately d=0.20 [small effect size]. 

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Interview by Greg Arnold (Psychotherapy.net)

There are a number of trials that compare a coherent, cogent, structured treatment to what’s often called “supportive therapy,” where the patient just sits with an empathic therapist, but there’s no treatment plan, there’s no explanation to the patient about what they’re going to do in therapy to help them get better. And we know, all the way back to Jerome Frank, that we need a coherent explanation for what’s bothering the patient and a believable treatment for them—something for the patient to do so that they work hard to overcome their difficulties. Supportive therapies are a lot more effective than doing nothing, but they’re not as effective for targeted outcomes as those that have a coherent explanation and treatment plan. So if a patient comes in with problems in interpersonal relationships, depression, anxiety, we have to come up with a cogent explanation and a believable treatment to overcome their difficulties. As long as what they’re doing is believable, accepted, is given by a therapist who’s skilled and believes in the treatment as well, the treatment tends to go well...

Of course, not all treatments are equal—there are harmful treatments...

We just did a study where we looked at therapists over almost 20 years of practice, and the therapists did not improve. In fact, they deteriorated a bit... What other profession do you go into a room, do your work in privacy, aren’t really allowed to talk about it because it’s confidential, and don’t get any feedback about how you’re doing. How can we expect to get better? Would we go to hear a musician who only performed and never practiced? Do you think world class tennis players just play Wimbledon and the U.S. Open and Australian Open? No, they practice hours a day on particular skills. So becoming a better therapist takes a lot of deliberate practice...

Effective therapists are able to form a working alliance—a collaborative working relationship—with a range of patients. The motivated patients with solid attachment histories who easily form an alliance with you—those aren’t the ones that challenge us. The ones that challenge us have poor attachment styles, do not have social networks, they alienate people in their lives, they have borderline features, they’re interpersonally aggressive, they tell us we’re no good. A really effective therapist is able to form a relatively good collaborative working relationship with those types of patients. The therapist effect is larger for more severely disturbed patients, which makes sense.

Effective therapists are also...persuasive as well as verbally fluent, so when they explain things, they do it in two or three sentences and it’s coherent. I have my students practice explaining what they’re going to do in therapy. It’s difficult to do and you have to practice until you can do it in three or four sentence.

An effective therapist can read the emotional state of clients even when they’re trying to hide it. And we know the patients hide what they’re feeling. It isn’t intentional; it’s part of their struggle in life. They suppress anger or they’re not allowed to express sadness. A good therapist can understand and respond to the patient affect. Good therapists also can modulate their own affect. Can you be expressive and activated when you have a really depressed patient who just kind of sits there? Affect is really contagious. We know that from basic science.

On the other hand, if we have an extremely anxious patient, can we be relaxed and calm? Modulating our own affect takes some practice as well. Are we warm, understanding, and caring? You may think all therapists are warm, understanding, and caring, but it takes work...Being warm and empathic is easy with some patients, but really hard with others"...

You need to modify treatment for some patients, or you might have to abandon it and do something very different for particular patients. Flexibility is another characteristic of effective therapists. That doesn’t mean doing something different every week with them, which is confusing; we need to be consistent, but also flexible...

You don’t want to be so flexible that you lack coherence, as that is not effective either. We need to be kind of in that sweet spot where there’s consistency in what we’re doing so the patient feels like we’re working towards their goals with a logical treatment plan. But there may be a crisis in a patient’s life or a dramatic event or they’re just resistant. One of the things I teach my trainees is to see the nonverbal signs of resistance—they’re not following through on activities or when we explain what we’re doing they look away. They don’t want to say, “No, that doesn’t make sense, you’ve got it wrong.” So we have to be really attuned to those signs and willing to explore them...

CBT therapists are great at this. They incorporate psychoeducation into the treatment structure, so a coherent treatment plan is central to the work they do with clients. Where CBT therapists can fall short if they don’t attend to it is the warm, empathic, understanding treatment expectation part of the contextual model. If you administer CBT without warmth and understanding, it’s not going to be nearly as effective. On the other side are the humanistic therapists who are often great at the warm, empathic part of therapy but don’t always have a coherent treatment structure...

I have no problem with treatment protocols. I think people should be relatively fluent in several. And we should recognize our limitations. If we’re psychodynamic and have a client who is more interested in doing CBT, or we think would be better served by a CBT therapist, we should refer them out. We often have this belief that we can help everybody, but it’s really not true...

I’m involved in a start-up company, TheraVue that’s dedicated to online skill building for psychotherapists...

[Interviewer:] We recently did an interview with Tony Rousmaniere on deliberate practice, although we haven’t published this yet. It’s a concept he learned from Scott Miller that involves literally practicing—like tennis players do between games—the skills of therapy outside of the therapy office. Videotaping ourselves, practicing how we talk, having mentors watch our work, trying to eliminate things that aren’t helping clients—weird idiosyncrasies we wouldn’t necessarily pick up without an outside observer. Are these the kinds of practices you are talking about?

[Wampold:] Yes, exactly. You can’t just reflect and think about your practice, just do process notes or whatever. It’s important to do those things, and certainly one of the characteristics of effective therapists is professional humility. Good therapists, the ones that get better outcomes, are the ones who say, “I’m not sure I’m helping patients. I need to get better.” But Daryl Chow and Scott Miller did a study that revealed that people who work outside of their practice to get better actually have better outcomes.

The skills I’ve talked about, you have to do them over and over again with feedback from somebody. This is what we’re doing with practicum students now. Often students will go, “I’m an advanced student now; these are basic skills you’re teaching.” No, we all need to practice these things. By the end, they often say, “this was the best practice class I’ve ever had because we actually practiced the skills we use in therapy"...

[Outcomes.] I would add that, in my experience, and I think the research supports this, discussing the feedback with patients is helpful. What it communicates to the patient is that you are improving and that their feedback actually matters to you. But it also makes it clear that the focus is on, “Are you getting better?” I want to know that continually. We should all be discussing with our patients how therapy is going and how we can change to more readily support their goals. That’s a tremendously powerful message when we discuss that with patients. If we’re not meeting the goals, what can we do differently? Some would call that client-informed, but all therapists are client-informed. To a large degree, we should all be discussing with our patients how therapy is going and how we can change to more readily support their goals.