All Eyes on the Prize (Looking through Different Glasses)
Psychotherapists and psychotherapy researchers all want the same thing: less mental illness and greater psychological well-being, for the most people, using the least resources. Historically, though, there has been some disagreement about how best to achieve effective and efficient psychotherapy outcomes. The disagreement manifests both in clinical practice and in research. Differences include:
- Interpretation of existing research findings’ implications about what interventions should be disseminated to improve mental health.
- Beliefs about what types of research are most likely to produce results that will move us closer to the above consensual aims.
The Common Factor and Empirically Supported Treatment Perspectives: Bridges and Chasms
We speak here of the long-standing debate over whether “common factors” (CFs) that are present in virtually all treatments are sufficient to achieve change, or whether clinicians should adhere solely (or at least predominantly) to “empirically supported treatments” (ESTs)—manualized, theory-specified intervention packages tested in randomized clinical trials (RCTs; Laska, Gurman, & Wampold, 2014; Wampold, 2001). A recent issue of the journal Psychotherapy revived this debate, featuring 10 commentaries by diverse voices in the field, including ours. Though the dialogue revealed continued points of contention, it also illuminated considerable areas of convergence among these traditionally divergent “camps.”
Most parties agreed that:
- The therapy relationship is important.
- The distinction between “common” and “specific” factors is artificial: CFs are not inherently “nonspecific” interventions, and many so-called “specific” techniques are present across therapy “brands.”
- Good therapists are flexibly responsive, applying techniques that are appropriate to the clinical situation, rather than rigidly adherent.
- Certain presentations call for certain specific techniques (e.g., exposure for anxiety).
- Cost-effectiveness and disseminability, not just efficacy, are relevant criteria for choosing treatments.
- Effective treatments need to apply across clinical diagnoses, as training therapists in highly disorder-specific “packages” is inefficient.
- What therapists do should be based on scientific evidence.
Many of those who expressed doubts about the utility of a CF “approach” (i.e., a therapy consisting necessarily and sufficiently of an emotionally-charged patient-therapist relationship, a healing setting, an explanation for mental illness, a credible rationale for change, and rationale-relevant techniques; Laska et al., 2014) argued that it might not have implications for clinical practice unless we can:
(1) empirically identify those mechanisms of change that appear across treatments, and
(2) cost-effectively disseminate training that enhances those therapy elements.
In turn, some proponents of CFs implied that, if the amount of variance in outcome due to a treatment package is minimal (a belief not shared by all discussants), it is wasteful to continue to investigate and disseminate said treatment packages.
Collectively Moving Forward
Given these points of convergence and remaining disagreements, what could be the next fruitful steps for moving the field forward? It appears that all stakeholders want to identify core change mechanisms in psychotherapy, and that it would be ideal to determine whether we can capably train therapists to deliver those mechanisms, whether they have traditionally been classified as CFs or model-specific techniques, at the appropriate time.
We envision a paradigm shift in evidence-based practice and training that can fulfill these next steps, thereby moving us closer to achieving the goals of psychotherapy. The shift need not be jarring. Scientifically, it is a natural extension and integration of the aforementioned positions of both CF and EST practitioners and researchers. Clinically, it is consistent with what good therapists already do, and with the way humans in general think and learn.
Reconceptualizing CFs via Context-Responsive Psychotherapy Integration
We have proposed one attempt to synthesize the CF and EST perspectives, which we refer to as context-responsive psychotherapy integration (CRPI; Constantino, Boswell, Bernecker, & Castonguay, 2013; Constantino, Overtree, & Bernecker, 2013). CRPI is a reconceptualization of the CF perspective on psychotherapy. It seeks to move away from the often-misspecified application of the term CFs to relationship variables only (see Lambert & Ogles, 2014) and move toward the application to clinical scenarios (e.g., treatment processes, patient characteristics) that clinicians commonly encounter and to which they need to be effectively responsive.
Although CRPI will constantly evolve, two main principles will drive research, practice, and training:
(1) derive empirical markers of common scenarios/characteristics/themes, and
(2) develop evidence-informed ways of responding to these scenarios/characteristics/themes.
CRPI as an “If-Then” Venture
Specifically, CRPI suggests an if-then endeavor in which therapists respond to patients’ characteristics (from baseline through treatment) and emerging clinical scenarios (both in and out of session) with pointed, principle-driven, and evidence-backed strategies. These strategies would be common in that therapists could capitalize on them in any treatment context given their relevance and empirical support for addressing a commonly encountered scenario. Integration with ESTs comes in the form of clinicians providing a coherent mental illness conceptualization, treatment rationale, and relevant intervention (or what Jerome Frank, 1961, called “rituals”). Such elements, while they can be packaged differently in different empirically supported treatments, are also common in what they provide patients—i.e., hope, remoralization, and framework around which to mobilize internal and external change resources.
Thus, following CRPI, treatment could begin from any distinct orientation, and then shift into (and back out of) modular evidence-based practices in the face of markers that point to the need for such shifts. A few examples include therapist employment of:
- Rupture-repair strategies when sensing tensions in their working alliance with the patient (Hilsenroth, Cromer, & Ackerman, 2012).
- Motivational interviewing tactics when observing patient ambivalence about change (Westra, 2012).
When the above markers dissipate, therapists could return to their foundational approach for that patient (i.e., the approach that involved the rationale for the treatment goals and tasks). Thus, in CRPI, clinicians can maintain their preferred orientation (thereby aligning with their change philosophies), while also incorporating flexibly manualized responsiveness elements on which they can be trained efficiently. As noted, this paradigm shift need not jar! And for therapists who are integrative or cross-trained, they can have more rationale options to offer that might resonate with patients to instill hope, foster task/goal alignment, remoralize, etc.
Moreover, CRPI might be what effective therapists already do, with such responsiveness perhaps partly accounting for the common finding of outcome equivalence among active treatments (Stiles, Honos-Webb, & Surko, 1998). We argue that codifying/manualizing this type of responsiveness will theoretically allow *everyone* to be a good therapist.
CRPI Advantages: Conceptual
We see conceptual advantages to our reconceptualization of CFs within CRPI:
- The common clinical scenarios (e.g., alliance ruptures, patient change ambivalence) and responsive interventions modules (e.g., evidence-based rupture-repair techniques, MI techniques) that we have advanced are obviously not a comprehensive list; CRPI will evolve as additional empirically-supported markers and effective responses are identified.
- CRPI is not a static package to which proponents need to maintain an allegiance to one theory, though one can scratch this itch if it exists through providing a good theoretical treatment rationale and using a corresponding set of interventions, or rituals (which happen to be treatment activities with empirical support; Ahmed & Westra, 2009; Frank, 1961).
- The responsiveness modules themselves, if shown to favorably influence their target scenario (e.g., MI strategies causing reduced change ambivalence), need not have a comprehensive theory of pathology, treatment, and change—a criticism of the CF approach as currently stated (e.g., see Lambert & Ogles, 2014).
CRPI Advantages: Empirical
We also see research advantages to the CRPI approach:
- It defines a treatment “method” broadly—that is, as any therapeutic strategy and corresponding principle regarding when to apply it. Responsiveness modules can be manipulated and tested as causal, which is vital for CFs to gain legitimacy beyond a post hoc explanation for treatment equivalence (Crits-Christoph, Chambless, & Markell, 2014).
- As a whole, researchers can test CRPI training methods versus training-as-usual in graduate programs; researchers can also test the efficacy of adding specific CRPI modules to treatments or training (i.e., additive designs that isolate a module as a causal mechanism)
- Research that isolates person and process markers for shifting into and out of responsiveness modules could be hugely impactful for tailoring treatment to the person and the moment—a major step forward in answering what works for whom and when?
- The construct of therapist adherence could get more predictive mileage if reconceptualized as rationale-ritual congruence and if-then responsiveness.
CRPI Advantages: Dissemination and Implementation
Finally, CRPI has dissemination and implementation appeal.
- As research uncovers common contexts and effective responsiveness strategies to address them, it is much more reasonable and efficient for therapists (of any orientation) to engage in modular training for these contexts versus trying to learn hundreds of ESTs.
- Therapists are likely to make more use of empirically based interventions if they do not require drastic changes to their current clinical practice (CRPI does not require such changes and it purposefully builds on one’s preferred orientation).
- CRPI’s if-then nature draws on research on the cognitive capacities of humans; when plans are formed with an if-then structure, less cognitive control is required for effective implementation (Parks-Stamm & Gollwitzer, 2009).
- As CRPI evolves, so too can training; the field would not be required to hold onto a training model specified decades ago (e.g., the Boulder model), and training programs can incrementally revisit their methods in light of crucial evidence (versus relying on “guru-based” supervision and adherence to rather static accreditation criteria).
CRPI involves a reconceptualization of CFs toward clinical scenarios (e.g., treatment processes, patient characteristics) that clinicians commonly encounter and to which they need to be therapeutically responsive in some way.
We look forward to contributing to and consuming developments within the CRPI frame. In a first attempt to put the CRPI model into practice, we developed a CRPI training practicum at the University of Massachusetts Amherst. It involves:
- One semester of intensive training on a theory-driven model of psychotherapy through weekly didactic group meetings and individual supervision.
- Two semesters (including summer) of approximately five team-based meetings on each of the five starter responsiveness modules that we have proposed; that is, modular workshops involving didactics, observations, and experiential role-plays centered on evidence-based strategies for fostering expectations, repairing alliance ruptures, using MI spirit and technique, managing self-strivings, and responding to routine outcomes monitoring feedback with clinical support tools (Constantino et al., 2014).
Our approach fits our main premise that the most skillful therapists will know how to harness the power of a persuasive rationale (which could derive from an EST) and when and how to respond to common clinical scenarios and patient characteristics based on multi-method evidence.
Editor’s Note: Dr. Michael Constantino and Ms. Samantha Bernecker are affiliated with The Psychotherapy Research Lab – https://sites.google.com/site/constantinotherapyresearchlab/home
The authors recently published an article titled “Bridging the common factors and empirically supported treatment camps: Comment on Laska, Gurman, and Wampold” in Psychotherapy.
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