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

What is the evidence for the common factors in psychotherapy and how important are they to patient outcomes? In their landmark book, The Great Psychotherapy Debate, Wampold and Imel cover this ground is some detail, and I reviewed a number of the issues raised in their book in the PPRNet blog over the past year. This article by Wampold provides a condensed summary of the research evidence for the common factors in psychotherapy, including: therapeutic alliance, therapist empathy, client expectations, cultural adaptation of treatments, and therapist effects. Therapeutic alliance refers to therapist and client agreement on tasks and goals of therapy, and the bond between therapist and client. A meta-analysis of the therapeutic alliance included over 200 studies of 14,000 patients and found a medium effect of alliance on patient outcomes (d = .57) across a variety of disorders and therapeutic orientations. A number of studies are also concluding that the alliance consistently predicts good outcomes, but that early good outcomes do not consistently predict a subsequent higher alliance. Further, therapists and not patients were primarily responsible for the alliance-outcome relationship. Another common factor, empathy, is thought to be necessary for cooperation, goal sharing, and social interactions. A meta-analysis of therapist empathy that included 59 studies and over 3,500 patients found that the relationship between empathy and patient outcome was moderately large (d = .63). Patient expectations that they will receive benefit from a structured therapy that explains their symptoms can be quite powerful in increasing hope for relief. A meta-analysis of 46 studies found a small but statistically significant relationship (d = .24) between client expectations and outcome. Cultural adaptation of treatments refers to providing an explanation of the symptoms and treatment that are acceptable to the client in the context of their culture. A meta analysis of 21 studies found that cultural adaptation of evidence-based treatments by using an explanation congruent with the client’s culture was more effective than unadapted evidence-based treatments, and the effect was modest (d = .32). Finally, therapist effects, refers to some therapists consistently achieving better outcomes than other therapists regardless of the patients’ characteristics or treatments delivered. A meta analysis of 17 studies of therapist effects in naturalistic settings found a moderately large effect of therapist differences (d = .55).

Practice Implications

These common factors of psychotherapy appear to be more important to patient outcomes than therapist adherence to a specific protocol and therapist competence in delivering the protocol. As Wampold argues, therapist competence should be redefined as the therapist’s ability to form stronger alliances across a variety of patients. Effective therapists tend to have certain qualities, including: a higher level of facilitative interpersonal skills, a tendency to express more professional self doubt, and they engage in more time outside of therapy practicing various psychotherapy skills.

The Great Psychotherapy Debate: Since in April, 2015 I review parts of The Great Psychotherapy Debate (Wampold & Imel, 2015) in the PPRNet Blog. This is the second edition of a landmark, and sometimes controversial, book that surveys the evidence for what makes psychotherapy work. You can view parts of the book in Google Books.

The conduct of psychotherapy trials almost always requires that therapists be adherent and competent in delivering a manualized therapy intervention. Treatment adherence usually refers to the extent to which a therapist used the intervention prescribed by a treatment manual. Therapist competence refers specifically to a therapist’s skill in delivering the therapy. So “competence” in the context of psychotherapy research typically refers only to performing a certain type of treatment. Wampold and Imel argue that these definitions are consistent with a Medical Model of psychotherapy that emphasizes delivering specific active ingredients of a treatment. The Contextual Model of psychotherapy, on the other hand might define a therapist as competent to the extent that the therapist is interpersonally skilled, empathic, and able to engage clients in the actions of the therapy. Wampold and Imel report on a meta analysis of 28 studies conducted by Webb and colleagues (2010) who found a small and non-significant relationship between therapist adherence and patient outcomes (r = .02), and a small and non-significant relationship between therapist competence and patient outcomes (r = .07). Type of treatment (e.g., CBT, IPT, dynamic) did not affect these associations – in other words adherence and competence were not more important to CBT than to other treatments. However, competence seemed to be more important for the treatment of depression (r = .28). Perhaps depression responds better to specific techniques. The finding that competence was generally not related to outcomes was surprising, however generally competence is narrowly defined as how well a therapist delivered the treatment not how well the therapist was able to establish a therapeutic context. Previous researchers concluded that when clients liked working with a therapist, clients got better, and therapists were rated as more competent as a result. A number of studies appear to indicate that therapist competence is really a function of the client’s characteristics not to what the therapist does. For example, clients with more severe personality problems could make a therapist appear less competent, and these clients may have poorer outcomes. If this is the case, it would create a paradoxical situation in which therapists’ appearance of competence (i.e., ability to deliver a manualized intervention well) is largely determined by the client and not by the therapist.

Practice Implications

In contrast to the findings about adherence and competence, the therapeutic alliance is robustly related to patient outcomes. Also in contrast, the size of the alliance-outcome relationship is almost entirely due to the skills of the therapist, not the client’s characteristics. In other words, therapist competence is not a matter of whether they can do a good job of following a manual, but rather therapist competence is likely a matter of creating the right conditions (i.e., interpersonal skill, alliance, empathy, etc.) for delivering evidence-based interventions by which many clients improve. However, some therapists are better at these facilitative interpersonal skills than others.

The Great Psychotherapy Debate: Since in April, 2015 I review parts of The Great Psychotherapy Debate (Wampold & Imel, 2015) in the PPRNet Blog. This is the second edition of a landmark, and sometimes controversial, book that surveys the evidence for what makes psychotherapy work. You can view parts of the book in Google Books.

Wampold, B.E. & Imel, Z.E. (2015). The great psychotherapy debate: The evidence for what makes psychotherapy work (2^nd edition). New York: Routledge.

In this part of the book, Wampold and Imel reviewed the research literature on the therapeutic alliance. The therapeutic alliance is considered a pan-theoretical construct that is critical to the success of all psychotherapies. Alliance is defined as the: (a) agreement on the goals of therapy, (b) agreement on the tasks of therapy, and (c) the bond between therapist and client. Numerous meta analyses across several decades demonstrate a robust relationship between the alliance and therapy outcome. For example, Horvath and colleagues (2011) conducted a meta analysis with 190 studies that included over 14, 000 clients in which the average effect size was r = .28, indicating a moderate and significant association between alliance and outcomes. Some researchers argued that this is an under-estimation of the alliance outcome relationship. In Horvath and colleagues’ meta analysis, they found no difference between type of psychotherapy (CBT, interpersonal, dynamic) and the alliance – outcome relationship. However, the alliance may work differently in some therapies. For example, in CBT there is some evidence that the collaborative bond is not related to outcomes, but rather the agreement on tasks and goals is related to patient outcomes. This highlights that an alliance cannot happen without techniques; in other words, if techniques fail to engage the patient in the work of therapy, then the technique is not working properly. Wampold and Imel also reviewed the research on whether the therapist or the patient is most influential in developing an alliance. Using sophisticated statistical techniques, they were able to disentangle the effects of therapists and clients. More effective therapists were those who had stronger alliances with patients, and their patients had better outcomes. However, the patient’s contributions to developing an alliance were not significant. Finally, Wampold and Imel reviewed the research on whether early alliance causes good outcomes, or whether early outcomes causes a good alliance. If the latter were true, then the therapeutic alliance would simply be an artifact of early improvement – that is, the alliance would not be necessary for patients to improve. Most of the studies, which were conducted by researchers of different theoretical orientations, concluded that early alliance predicts outcomes and not the other way around. There is some evidence that change in the alliance and change in symptoms have a reciprocal impact – as the alliance grows the patient subsequently improves and as the patient improves the alliance subsequently grows.

Practice Implications

Clearly, developing and maintaining a therapeutic alliance is important to achieving good patient outcomes in psychotherapy. The alliance is not independent from techniques of psychotherapy. In other words, therapists and clients have to agree on the tasks and goals of treatment, and this agreement is fundamental to all treatment modalities offered to patients. If there is no agreement, then therapists have to consider changing course or discussing with the client ways of achieving an agreement. Over and above that, therapists and clients must have some interpersonal bond that is likely underpinned by the therapist’s empathy, positive regard, and concern for the client. The research is clear that it is the therapist who most strongly contributes to the development of an alliance, and so it is the therapist’s responsibility to nurture a positive working alliance.

Safran , J. D. & Kraus , J. (2014). Alliance ruptures, impasses and enactments: A relational perspective. Psychotherapy, 51, 381-387.

In this clinically oriented review, Safran and Kraus discuss the evidence related to alliance ruptures, repairing alliance ruptures, and methods of training in alliance rupture repair. Safran’s work represents “second generation” research on the therapeutic alliance. The therapeutic alliance refers to the relational bond between client and therapist and their agreement on tasks and goals of therapy. A positive alliance is associated with good client outcomes across a variety of therapeutic approaches. Therapeutic alliance ruptures in psychotherapy are inevitable, such that the alliance is continually being re-negotiated, both implicitly and explicitly, throughout the therapy. Such ruptures might include strains, tensions, or breakdowns that could interfere with the ongoing collaboration between therapist and client. Ruptures are associated with re-enactments of dysfunctional relational patterns, but they also may provide opportunities for change and growth in therapy. Safran’s model of alliance ruptures and repairs sees the processes in the client-therapist relationship as key to understanding the client’s relationship problems. Collaboratively addressing tensions in the alliance allows the client to develop more flexible ways of being in relationships and of experiencing themselves. Research by Safran and Muran (2000) suggest that it is rare not to have some minor strain occurring in the therapeutic alliance. Ruptures may occur in half of therapy cases within the first six sessions. Research indicates that unresolved ruptures are associated with deterioration in the alliance, poor outcome, and patients dropping out. In a meta-analysis, repairing alliance tensions by using evidence-based strategies was associated with improved patient outcomes and the effect was large. Alliance ruptures occur across theoretical orientations. For example, research on cognitive therapy showed an improvement in therapist-client interpersonal processes after therapists were trained in techniques to resolve alliance ruptures.

Practice Implications

Alliance ruptures can range in intensity from minor tensions to major rifts in collaboration. They may occur at any time in treatment, and may be present in single or across multiple sessions. Safran and Kraus describe two general types of ruptures. First, withdrawal ruptures occur when clients deal with ruptures or misunderstandings by falling silent. The resolution may involve the therapist exploring the client’s interpersonal fears, reasons for inhibiting negative feelings, and providing the client with an opportunity to communicate their needs. Second, confrontation ruptures occur when clients directly express anger, resentment or dissatisfaction with the therapist or therapy in a blaming manner. The resolution may involve the therapist empathically engaging with the client to facilitate feelings of disappointment, hurt, and vulnerability. Key to this process is the therapist’s meta-communication or mindfulness abilities. The therapist must be aware of the behavior associated with the rupture, collaboratively explore the rupture experience, help the client overcome avoidance of feelings related to the rupture, and explore the client’s needs and wishes that emerge while working through the rupture.

Hoglend, P. (2014). Exploration of the patient-therapist relationship in psychotherapy. American Journal of Psychiatry, 171, 1056-1066.

In this overview of patient-therapist relationship factors, Per Hoglend reviews research on transference in psychotherapy. He argues that transference and transference work is a specific technique that focuses on exploring the patient-therapist relationship. Hoglend takes a broad definition of transference as: the patient’s pattern of feelings, thoughts, perceptions, and behaviors that emerge in the therapeutic relationship and reflect the patient’s personality functioning. Hoglend also defines transference work as any therapist intervention that refers to or explains the patient’s experience of the therapist and their interaction. These interventions include the therapist: (1) addressing transactions in the patient-therapist relationship; (2) encouraging exploration of feelings and thoughts about the therapy or therapist; (3) encouraging the patient to discuss how he or she believes the therapist might feel or think about the patient; (4) including him or herself in interpreting the patient’s dynamics; and (5) interpreting repetitive interpersonal dynamics and linking these to the therapy relationship. More than 30 studies have been published on providing empirical evidence for the relationship between transference work in psychotherapy and positive patient interpersonal outcomes. Effect sizes of the association between transference work and patient outcomes tend to be large. Some of the research indicates that low frequency of transference interventions is useful, but that a higher frequency may lead to negative effects on the patient. Research on transference-focused psychotherapy indicates that it is as effective as dialectical behavior therapy and supportive psychotherapy for borderline personality disorder, but that transference-focused therapy produced better outcomes for attachment related functioning like mentalizing. In the First Experimental Study of Transference Work (FEST), Hoglend found that patients with low quality of object relations (i.e. a poorer ability to maintain close relationships and to regulate affect) benefited most from transference focused therapy. However, those with high quality of object relations did not require the transference work to get better. Also, women responded better to transference work than men. There are some studies of therapeutic approaches like cognitive behavior therapy, in which patients with depression had better outcomes when the patient-therapist relationship was explicitly discussed.

Practice Implications

Hoglend argues that transference work in psychotherapy is an active ingredient that can lead to specific change in some patients. Most studies that Hoglend reviewed showed significant and large associations between transference work and interpersonal changes in patients. Exploring the patient-therapist relationship appears to be most useful for female patients, those with difficult interpersonal relationships, and those with more severe personality pathology. Patients with more mature relationships may not benefit as much from transference work. Although generally effective, if transference work is used too frequently in a session it can also lead to negative patient outcomes.

Tracey, T.J.G., Wampold, B.E., Lichtenberg, J.W., & Goodyear, R.K. (2014). Expertise in psychotherapy: An elusive goal? American Psychologist, 69, 218-229.

As I have reported many times in this blog, there is substantial evidence for the efficacy of psychotherapy. However, the quality of psychotherapy differs across therapists – that is, some therapists achieve better client outcomes than others. Tracey and colleagues (2014) ask: is it possible to demonstrate expertise in psychotherapy? They define expertise as “increased quality of performance that is gained with additional experience”. Professions that can demonstrate expertise include: astronomers, test pilots, chess masters, mathematicians, and accountants. But several professions may not demonstrate expertise, including: psychiatrists, college admissions officers, court judges, personnel selectors, and psychotherapists. The difference is that the former group has predictable outcomes and has access to quality feedback. In addition, Tracey and colleagues argue that psychotherapy lacks adequate models for how interventions produce benefits. As a result, adherence to treatment protocols (i.e., manuals) is not reliably associated with better patient outcomes. Further, more experienced therapists are not more effective than less experienced therapists. Experienced therapists might have more complete conceptualizations of client problems, but these conceptualizations may not be accurate. Finally, although therapists affect outcomes, client variables (e.g., motivation, severity of symptoms, expectations) likely explain the largest proportion of outcome variance. Tracey and colleagues argue that part of the problem is that psychotherapists do not engage in “deliberate practice”; that is, practice of a specific task (e.g., identifying a rupture in the alliance), receiving specific feedback (e.g., that a rupture was not identified), opportunity for repetition (e.g., to identify a subsequent rupture in the alliance), and opportunity for improvement afforded by error (e.g., better able to identify a future rupture and repairing that rupture). Generally the practice of psychotherapy provides little feedback about the accuracy of past clinical decisions. In other words there is a lack of quality information to help therapists develop into experts. Further, for a whole host of reasons, psychotherapists are notoriously poor at assessing client progress (i.e., like other humans, therapists engage in a number of biased evaluations of their performance). Quality information might be available from progress monitoring (i.e., continuous feedback to therapists about client outcomes), which has been shown to improve client outcomes. However, this may not aid therapists in developing expertise, since progress monitoring provides little information about what therapist behaviors are necessary to improve performance and client outcomes.

Practice Implications

Tracey and colleagues conclude that currently psychotherapy does not provide evidence that it is a profession with expertise. To achieve expertise, therapists need quality information not only about their patients’ outcomes but also about their own average outcomes (i.e. performance) relative to other therapists working with similar clients. And therapists need information on how to manage specific events in psychotherapy. Tracey and colleagues suggest therapists set aside time to generate hypotheses about one’s practice that can be disconfirmed, and then test these hypotheses. For example, if a therapist is experiencing a higher than average number of premature client terminations (which may follow a misunderstanding with the client), the therapist may hypothesize that he or she is not identifying key alliance ruptures. To test this hypothesis, the therapist could repeatedly assess the alliance (with a validated instrument) with some clients, use this information and not clinical judgement alone to identify alliance ruptures (i.e., a week to week severe downward trend in alliance scores), and implement an intervention to repair the alliance with these clients. Do clients with whom a therapist has implemented this procedure drop out at a lower rate? Does this process of deliberately identifying alliance ruptures and repairing them lead to enhanced therapist performance regarding alliance ruptures? This form of deliberate practice (testing disconfirmable hypotheses based on quality information) might lead to greater expertise in identifying alliance ruptures.