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Writer's pictureJeremy Smith

A quick summary of common factors in effective psychotherapy

Updated: 6 days ago

The common factors movement is the result of studying multiple theories to determine what they have in common and what factors are associated with therapeutic success.


The big idea

Although a therapeutic model serves as a vehicle, the therapeutic alliance, therapist’s confidence, and client motivation, including hope and expectancy, are more responsible for change than the details of a specific model [1,2,3]. This doesn't mean that model-informed “concrete skills” are unimportant — only that they explain less of the variance in therapeutic outcomes (perhaps 8-15%) than other factors [1,2].

Dialing down

Client, or extratherapeutic, factors may account for approximately 40% of client improvement [4]. Some clients improve without extensive psychotherapy; others improve rapidly with treatment; and others have high spontaneous remission rates (particularly in cases of depression — the highest remission rates, anxiety, and phobic and hypochondrical disorders and OCD) [1]. The client’s disposition — including motivation and expectation for improvement (explaining ~15% of variation in therapeutic outcomes) — partially accounts for this improvement. More ingrained components such as personality style, inner strength and personal agency, religious faith, and goal-directedness, also profoundly influence the duration of symptoms and the probability of remission. The presence of an underlying personality disorder, and the nature and quality of social support (especially in the closest relationships, such as spousal relationships) are also key determinants of therapeutic success [1,4].

It has been estimated that therapist-client relational factors may account for approximately 30% of therapeutic efficacy [1]. The therapeutic alliance aspect is comprised of Rogerian, humanistic, facilitative conditions including warmth, congruence, and empathy, and encompasses the client’s personal factors, the therapist’s interpersonal skills and style, and the working alliance between the client and the therapist. All of these factors facilitate a positive transference-countertransference relationship and, consequently, mutual positive regard and a consensus on and commitment to therapeutic goals [1,2]. In family therapy, this rapport is multidimensional because the therapist must engage (join) with multiple clients and maintain relationships with all of them simultaneously [2,4]. In fact, the unique context of MFT requires additional factorial considerations, including the systemic conceptualization of relationships, the expansion of treatment to all family members attending therapy and the consequent expansion of the therapeutic alliance to all members, and the model-informed assumptions about the influence of behavioral, cognitive, and emotive dynamics in the change process and client experiences [4]. Alteration of communication and behavioral patterns and inculcating a willingness in all family members to listen to, understand, and respectfully respond to others’ points of view, facilitated through strength-focused interventions in a “safe” therapeutic environment, appear to be primary common factors in the efficacy of systemic therapy across models, although, again, the previous observations regarding the primacy of client/extratherapeutic factors and the therapeutic alliance are still applicable to the systemic approach [4].

Fife and colleagues view the closely-related idea of the therapist’s “way of being” as even more foundational to therapeutic efficacy. This encompasses Rogers’s “unconditional positive regard” and Satir’s emphasis on valuing clients and their strengths, but also the more abstract aspects of the therapist’s “goodness,” acceptance/openness, or receptiveness. To paraphrase Martin Buber, who we are is who we are with others, and as therapy is not simply a technical practice but a humanistic one, it requires authenticity and “aliveness” [2]. In contrast to the objectification of the client in research, therapeutic practice requires that the therapist gives the client’s humanity primacy over their own emotional reactivity, which requires deep awareness of the therapist’s thought processes and motives [2].

In summary, although it is difficult to assign specific weights to these common factors, the current quantitative evidence suggests a clear (relative) hierarchy of their importance in therapeutic efficacy: the background and position of the therapist and client, as well as their trust and rapport, are foundational, whereas the literature lends less weight to model-specific/concrete skills/theoretical orientation. These observations do not, however, mean that model-specific approaches are unimportant, or that the common factors can be conceptually separated from each other -- they are interrelated. For example, client factors and the therapist’s ability to establish a safe and efficacious therapeutic “sandbox” are part and parcel of the systemic approach in family therapy, and the way these are implemented in practice is informed by theory underlying specific approaches. If anything, these factors are emphasized more in family therapy than in individual psychotherapy, since there are more clients with whom to establish a relationship and who contribute their own backgrounds and histories.

Caveats

Studies of the influence and importance of these common factors is complicated in two ways: first, some factors, such as “therapeutic alliance,” account for more explanatory variance than others, and, second, analyzing the factors independently is impractical, since they influence each other [2].

References & Further Reading

  • Asay, T. P., & Lambert, M. J. (1999). The empirical case for the common factors in therapy: Quantitative findings. In M. A. Hubble, B. L. Duncan, & S. D. Miller (Eds.), The heart and sould of change: What works in therapy (pp. 23-55). American Psychological Association. https://doi.org/10.1037/11132-001

  • Blow, A. J., & Sprenkle, D. H. (2001, Jul). Common factors across theories of marriage and family therapy: A modified Delphi study. Journal of Marital  and Family Therapy, 27(3), 385-401. https://doi.org/10.1111/j.1752-0606.2001.tb00333.x

  • Fife, S. T., Whiting, J. B., Bradford, K., & Davis, S. (2014). The therapeutic pyramid: A common factors synthesis of techniques, alliance, and way of being. Journal of Marital and Family Therapy, 40(1), 20-33.

  • Messer, S. B., & Wampold, B. E. (2002). Let's face facts: Common factors are more potent than specific therapy ingredients. Clinical Psychology: Science and  Practice, 9(1), 21-25.

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