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Starting Off on the Right Foot: Common Factor
Elements in Early Psychotherapy Process
Jared A. DeFife
Emory University
Mark J. Hilsenroth
Adelphi University
Effective psychotherapy builds on a strong foundation developing as early as
the first session. The aim of this review is to identify clinical research related
to nonspecific (i.e., common factors) treatment effects and to expand upon
those findings in developing techniques for applied clinical practice. Clini-
cians across treatment modalities can implement these techniques that are
informed by empirical evidence in an effort to develop a collaborative
treatment relationship with new patients. Three therapeutic principles iden-
tified in this review are: fostering positive expectancies, role preparation, and
collaborative goal formation. Research related to these factors is reviewed as
are suggestions for implementing them into applied clinical practice during
early treatment interventions.
Keywords: common factors, goal collaboration, role preparation, positive expectancies,
early treatment interventions
Preparation and collaboration are essential to the successful execution
of any team or group effort. Similarly, a solid foundation of a therapeutic
relationship allows for greater success as treatment develops. The early
development of the therapeutic relationship contributes to positive treat-
ment outcomes (for a review, see Hilsenroth & Cromer, 2007) and may
even be essential to the continuation of the therapeutic work (in terms of
reducing early attrition/termination). Positive expectancies, role prepara-
tion, and collaborative goal formation are three core psychotherapeutic
factors that influence early psychotherapy process and are empirically
linked with subsequent treatment adherence and outcome. These thera-
Jared A. DeFife, Department of Psychology, Emory University; Mark J. Hilsenroth,
Derner Institute of Advanced Psychological Studies, Adelphi University.
Correspondence concerning this article should be addressed to Jared A. DeFife, 36
Eagle Row, Westen-Lab, Atlanta, GA 30322. E-mail: jdefife@emory.edu
Journal of Psychotherapy Integration © 2011 American Psychological Association
2011, Vol. 21, No. 2, 172–191 1053-0479/11/$12.00 DOI: 10.1037/a0023889
172
peutic process elements are considered common factors as they are not
linked to specific theories of human development, psychopathology, or
psychotherapy and are endemic to multiple treatment modalities (Lam-
bert, 2005).
This review follows a common factors approach to psychotherapy
integration by identifying effective core ingredients found across forms of
psychotherapy and exploring methods and techniques by which those
process elements can be facilitated and enhanced (Norcross, 2005; Stricker
& Gold, 1996). We will review research linking therapeutic outcome to
positive expectancies, role preparedness, and goal agreement followed by
exploration of techniques for actively harnessing these positive elements in
the early stages of psychotherapy.
GREAT EXPECTATIONS
Early in treatment, clinicians may find importance in exploring what
the patient’s expectations of their work together are (cf. Van Audenhove
& Vertommen, 2000). Starting from a similar domain, we begin by exam-
ining the literature regarding the expectations of and beliefs about thera-
peutic process held by potential clients.
Freud wrote that “expectation colored by hope and faith is an effective
force with which we have to reckon . . . in all our attempts at treatment and
cure” (Freud, 1905/1953, p. 289). Subsequent research has borne out his
statement by addressing the importance of assessing what clients expect on
entering treatment and how those expectancies may impact the progression
of subsequent treatment. Jerome Frank et al. (1959) compared treatment
effects across three forms of psychotherapy: group therapy, individual
therapy once a week, or minimal contact treatment not more than one half
hour every 2 weeks. After 6 months, patients in all three therapies, as well
as patients who terminated within the first four sessions, showed on aver-
age equal changes in well-being. In a follow-up study, Frank et al. (1963)
examined the positive effects of placebo administration in alleviating pa-
tient ratings of discomfort. This work led Frank (1961/1973, 1982) to
develop his views on the roles of persuasion and expectation in the treat-
ment process. He elucidated various components shared among therapeu-
tic modalities, discussing the importance of fostering positive expectations
and change attributions within a collaboratively formulated, emotionally
charged and confiding relationship.
Expectations are at work even before treatment begins, as Snyder et al.
(1972) observed that many possible clients are deterred from seeking
therapeutic services because of holding low expectancies of receiving help.
173Common Factors in Early Treatment
Negative expectations may contribute to whether or not patients remain in
treatment after the initial interview (Heilbrun, 1970) and appear to nega-
tively impact therapeutic effectiveness (Goldstein, 1962; Kraus et al., 1969).
Studies across therapeutic modalities identify patients achieving significant
reduction in symptoms even before attending their first psychotherapy
session (Beckham, 1989; Frank et al., 1959, 1963; Friedman, 1963; Kellner
& Sheffield, 1971; Piper & Wogan, 1970; Shapiro et al., 1980). Degree of
pretreatment symptom improvement is significantly related to positive
treatment expectations (Friedman, 1963; Goldstein, 1960) and the dose-
effect meta-analysis of psychotherapy outcome performed by Howard,
Kopta, Krause, and Orlinsky (1986) suggested that about 15% of patients
achieved measurable improvement associated with making an initial psy-
chotherapy appointment.
In a more recent review of numerous dosage and phase model studies
of psychotherapy, Howard et al. (1996) termed the initial phase of thera-
peutic improvement “remoralization.” Individuals beset by turbulent
emotional and relational difficulties may quickly become despondent and
hopeless, triggering a vicious circle of poor coping and increased social or
emotional upset. This phenomenological experience of hopelessness may
be the most amenable challenge faced early in treatment as patients
connect with a service provider offering a mutable, more hopeful life
approach. Upon examining the expectations reported by a group of clients
who had completed a course of short-term psychotherapy, Dimcovic (2001)
noted that the majority of these clients harbored moderate or “realistic”
expectations for their therapeutic change, that client expectations became
more positive after they had started working with their therapist, and that
more positive expectations after the start of psychotherapy predicted a
greater degree of therapeutic change.
By manipulating client expectancies or disguising the therapeutic
intentions of systematic desensitization, many studies found reduced (or
even eliminated) therapeutic effectiveness for this form of treatment in
reducing anxiety (Kirsch, 1990; Kirsch & Henry, 1977; Leitenberg,
Agras, Barlow, & Oliveau, 1969; Lick & Bootzin, 1975; Marcia, Rubin,
& Efran, 1969). That is, clients’ anxiety may be reduced by their
expectations for receiving a powerfully effective treatment more so than
through the specific techniques used in standard desensitization proce-
dures. Kirsch (1990) reviewed 15 studies using expectancy modifications
(i.e., where individuals were informed before intervention that they
were about to receive a very powerful treatment) before comparing the
efficacy of desensitization treatments and control treatments for various
specific phobias. Of these studies, 13 showed negligible differences
between the desensitization treatments and the control conditions. One
study actually showed the control treatment to be more effective than
174 DeFife and Hilsenroth
desensitization, an effect achieved by informing the control group (but
not the desensitization group) that they were about to receive a pow-
erful treatment for their specific phobia (Tori & Worrell, 1973). Only
one study (Gelder et al., 1973) demonstrated greater efficacy for desen-
sitization; however, this effect was found on only one self-report mea-
sure and was limited to certain phobias. Kirsch (1990) noted that the
greater efficacy in the Gelder et al. study may be accounted for because
the pretreatment interview for the control condition was less effective
than the one used for the desensitization treatment in modifying indi-
viduals’ positive expectations for treatment.
Placebo control studies also provide some insight into the impact of
expectancies on subsequent therapeutic outcome. For example, Mon-
crieff, Wesseley, and Hardy (1998) suggest that antidepressant efficacy
is substantially influenced by a placebo effect. Their meta-analysis
demonstrated only a small effect size (ES ⫽ .17) in mood improvement
when comparing antidepressants to “active placebos” (i.e., placebos
that mimic the side effects of an antidepressant). In a substantial
meta-analysis that collected numerous effect sizes reported from over a
thousand psychotherapy studies, Lambert and Bergin (1994) reported
an aggregated within groups effect size for clinical management or
placebo control groups versus no-treatment conditions of .42, over half
of the .82 effect size found when comparing average psychotherapy
outcome to no-treatment controls (p. 151). Clearly these findings sup-
port the value of psychotherapeutic treatment above and beyond ex-
pectancy effects, but they also highlight the powerful effect of some
factor(s) found in placebo control conditions. Further meta-analyses of
placebo effect sizes include Lipsey and Wilson (ES ⫽ .44; Lipsey &
Wilson, 1993) and Grissom (ES ⫽ .48; Grissom, 1996). Again, these
studies reinforce that therapists are actively bringing about changes in
their patients above and beyond no-treatment and placebo controls, but
Lambert (2005) notes that such studies are also one type of methodol-
ogy involved in isolating possible causal mechanisms of patient im-
provement. One placebo control study meta-analysis (Barker, Funk, &
Houston, 1988) expanded on these findings by examining possible mech-
anisms of action in placebo conditions; measures of patients’ expecta-
tions were not significantly different in patients entering bona-fide
treatment versus those entering placebo control treatments.
In light of such pervasive research findings, Weinberger (1995; Wein-
berger & Eig, 1999) concluded that expectancies form a major common
factor (along with the therapeutic relationship, exposure to and confron-
tation of problems, experiences of mastery or cognitive control over prob-
lems, and attributions of therapeutic outcome) causally involved in creating
therapeutic change through varied therapeutic approaches. He further
175Common Factors in Early Treatment
advocated that certain common factors are highlighted in certain treatment
modalities while other factors are relatively neglected, contributing to
comparative psychotherapy research findings of outcome equivalence.
Greenberg, Constantino, and Bruce (2006) conducted a thorough review of
expectancy research related to psychotherapy process and outcome. They
concluded that expectancy effects substantially affect psychotherapy out-
come and the importance of the effects are frequently overlooked. Thus,
greater focus on harnessing the commonly ignored factor of expectancies
(as well as the other common factors described), should lead to more
effective and lasting outcomes.
How can clinicians capitalize on research findings of the importance of
fostering positive expectancies and translate them into applied clinical
practice? Frank (1973, 1982) suggested two factors contributing to the
remoralization of patients despairing of psychological ills: (1) developing a
rationale, conceptual scheme, or myth that provides a plausible explana-
tion for the patient’s symptoms; and (2) prescribing a ritual that requires
active participation of both patient and therapist and that is believed by
both to be the means of restoring the patient’s health.
Before a patient and therapist can collaboratively develop a ratio-
nale, conceptual scheme, or myth (many psychotherapists may prefer
the term “narrative” to the spiritually connotative “myth”) explaining a
patient’s symptoms, they must first understand together what those
symptoms are. Questions asked early in the first meeting such as “What
brings you to seek treatment?,” “What’s important in your life right
now?,” “What challenges have you been facing lately?,” “What led you
to eventually pick up the phone and call the clinic/office?” may facilitate
the discussion of these presenting problems. Hilsenroth, Peters, and
Ackerman (2004) demonstrated how an extended therapeutic assess-
ment integrating psychological assessment and the provision of clinical
feedback contribute to beneficial therapeutic outcomes and reduced
termination rates.
Once these symptoms are formulated, a therapist and patient work
together to develop an understanding or rationale that is experienced as
plausible. As behavior is multidetermined, clinicians from different
practice orientations will focus on diverse conceptualizations of what
contributes to symptom development. Just as a few broad examples:
Luborsky (1996) advocated identifying recurrent maladaptive relational
patterns related to symptomatic responses, while Beck (1979) discussed
raising hypotheses about the automatic thoughts contributing to mal-
adaptive affect and behavior, and Linehan (1993) described the use of
behavioral analysis with patients to develop a conceptual understanding
of problematic behavior. It is vital that patients and therapists work
176 DeFife and Hilsenroth
together to identify how the data accumulated in session fits into the
clinical formulation.
In addition to the actual content of the clinical formulation, the rela-
tionship in which the formulation is developed is also a major factor
contributing to the utility of that conceptualization. Ackerman and Hilsen-
roth (2001, 2003) reviewed the empirical literature to identify therapist
characteristics and techniques that either positively or negatively affect the
therapeutic alliance. Qualities such as the therapist being flexible, honest,
alert, and warm coupled with interventions such as accurate interpretation,
support, and facilitating affective expression were found to increase ther-
apeutic alliance. In a practice review, Hilsenroth and Cromer (2007) cov-
ered empirical findings on and provided process dialogue examples of
gathering assessment data, developing a clinical formulation, and supplying
patient feedback in ways to facilitate a positive therapeutic alliance. Mark-
ers for recognizing when formulation is contributing to positive expectan-
cies include patients stating that they feel understood, acknowledging that
their difficulties make more sense, expressing confidence in the treatment,
and identifying eagerness to return for further treatment sessions.
In addition to helping patients feel remoralized through collabora-
tive formulation, clinicians must also engender confidence in the pre-
scribed treatment. Based on their review of the literature, Greenberg et
al. (2006) suggest that “any treatment approach (especially those with
empirical support) should be convincingly presented as producing rel-
atively reliable and typically gradual change over time” (p. 671). Ther-
apists should be honest and confident in discussing their credentials,
their treatment experience, and the types of problems they typically see.
Often, when patients inquire about such topics, they may be approach-
ing the issue of trust. Therapists can acknowledge that trust is not
something that happens between two people right away, but that the
therapist is committed to staying present and involved, is enthusiastic
about working together, and hopeful that by allowing for working
through shared experiences that greater trust will develop over time.
There are many ways in which therapists can normalize peoples’
concerns and communicate realistic confidence in the treatment process.
The following statements highlight ways for helping individuals feel less
isolated with their problems and gain a greater sense of confidence in the
treatment: “the types of experiences you have described certainly sound
distressing, many people come to therapy with similar concerns, and they
are exactly the kind of concerns that therapy can be helpful with,” “I’m
glad you came in to seek help with this,” “I’m really hopeful that our work
together will be beneficial,” “I have seen many people describing similar
feelings get significant relief from treatment.” Consider the following state-
ment made to a patient from VandenBos (2008):
177Common Factors in Early Treatment
That shouldn’t have happened to you, it shouldn’t have happened to anyone, but
something awful did happen to you, and it hurt you, and anyone who experienced
what you experienced would have symptoms just like you are having now, but you
don’t need to stay this way, it can be changed, and by talking and exploring your life
and your experiences, you and I can change it, you will be able to better understand
what did and did not happen to you, and you can think afresh about the nature of
interpersonal relationships, so you can experience new events, such as our work
together, with a fresh, new view of events (p. 41).
Note how the above statement contains normalization (“anyone who
experienced what you experienced would have symptoms just like you”),
gives a brief introduction to the process of treatment (“by talking and
exploring your life and experiences”), and fosters positive expectations for
treatment (“you don’t need to stay this way, it can be changed,” “you can
think afresh,” “you can experience new events”).
In summary, therapists can help to realistically assuage anxieties by
normalizing their patients’ concerns as within the bounds of human expe-
rience, by expressing confidence in the effectiveness of the treatment
endeavor (to be supported by available evidence), and noting their com-
mitment to the development of the treatment relationship.
CHANCE AND PSYCHOTHERAPY FAVOR
THE WELL-PREPARED
In addition to engendering faith in the treatment rationale, patients
should be educated about the actual treatment process. It seems that the
early and active provision of information about and discussion of what
patients might expect from and how they might best participate in their
own treatment yields positive effects on the therapeutic progression. Or-
linsky et al. (1994) examined numerous studies concluding that “role
preparation produces better outcomes more often than not and does no
harm” (p. 282). The studies lend credence to the adage that “an ounce of
prevention is worth a pound of cure” by noting the beneficial effects of
addressing roles and expectations even before formal treatment has begun.
In researching the effects of psychoeducational interventions before
psychotherapy begins, Coleman and Kaplan (1990) examined the effects of
presenting a standardized pretreatment videotape informing children en-
tering psychotherapy and their mothers about the structure and process of
the psychotherapy the children were about to receive. Both children and
mothers who viewed the videotape demonstrated greater knowledge about
psychotherapy than individuals who had not viewed the videotape; young
children in the sample learned as much from the videotape as did adoles-
cents in the sample; and prepared children displayed fewer problematic
behaviors after four sessions of psychotherapy than nonprepared children
178 DeFife and Hilsenroth
who had also received psychotherapy. Their findings were echoed by
Shuman and Shapiro (2002) who found that materials designed to educate
parents about their children’s psychotherapy increased the accuracy of
parental expectations for treatment, and that parents with more accurate
expectations consequently had higher rates of treatment utilization.
Two similar studies examined the effects of presenting an 11-min
pretherapy orientation videotape to adult outpatients about to receive
psychotherapy. These studies found that patients who viewed the tape
effectively recalled and understood the information presented, showed a
greater decrease in self-reported symptoms than the control group after 1
month, positively rated their experience of viewing the tape (Zwick &
Attkisson, 1985), or had more accurate expectations of psychotherapy and
less state anxiety than nonoriented controls (Deane et al., 1992).
One standard role preparation utilized in psychotherapy trials is the
socialization interview (SI) developed by Lester Luborsky (1984), an in-
formative document addressing patient roles and potential expectations for
patients entering supportive-expressive psychotherapy. The SI reviews
what to expect in psychodynamic psychotherapy, outlines the patient’s and
clinician’s roles during treatment, and outlines potential reactions (both
positive and negative) to previously unexamined patterns or issues that
may arise during treatment. Ackerman et al. (2000) and Hilsenroth et al.
(2004) utilized this SI as one component of a collaborative feedback session
held during investigations into the beneficial effects of conducting a ther-
apeutic model of assessment that focuses on collaborative goal setting and
development of a therapeutic bond (Finn & Tonsager, 1992, 1997; Fischer,
1994). The varied benefits of conducting a therapeutic model of assessment
that included provision of the SI versus a traditional information gathering
model of assessment are described at length in Hilsenroth et al. (2004) who
identified significant reduction in early termination rates and stated that
“the presentation of the SI at this time enhanced the patient’s understand-
ing of psychotherapy and highlighted the relational focus of the therapeutic
process” (p. 337). In treatments where patients had received the SI, pa-
tients rated the statement “my therapist explained the rationale behind his
or her technique or approach to treatment” as one of the most highly
ranked items in a set of specific therapeutic techniques related to later
symptomatic improvement (DeFife, Hilsenroth, & Gold, 2008).
Even as role preparation is important at the outset of treatment, the
implementation of preparing patients for the treatment process is going to
vary widely among different treatment modalities and individual therapists.
However, there can be key targets and questions that practitioners should
develop answers for, and they can work to communicate those elements to
their patients early in treatment. One of the more basic elements to
negotiate is the nature of the treatment frame. Issues related to treatment
179Common Factors in Early Treatment
frame include length and frequency of sessions, expected duration of
treatment (i.e., time-limited vs. open-ended), and service fee.
A second factor in role preparation involves the discussion of what
patients are expected to bring to treatment: patients may be asked to
complete diary cards tracking emotional and behavioral experiences that
will be reviewed at the beginning of each session; the therapist might
inform patients about the value of completing tailored homework assign-
ments between sessions and/or highlight the importance of regular session
attendance and medication compliance. In a similar vein, patients should
be prepared with guidance about what types of content their therapies are
likely to focus on. Patients can be encouraged to discuss any number of
salient treatment themes such as behaviors that are distressing and prob-
lematic, upsetting thoughts that feel automatic, affects that are difficult to
experience, current or past relational interactions that have been unsatis-
fying, or even whatever comes to their minds during treatment. In his SI,
for example, Luborsky (1984) writes: “Ordinarily, people don’t talk about
lots of things because they are too personal, or because they would hurt
other people’s feelings, or for some other similar reasons. You will find that
with your therapist you will be able to talk about anything that comes to
your mind” (p. 198). Another example of preparation for open-ended
treatment process comes from Day (1993) who, as one part of developing
a treatment contract, encourages group patients “to feel free enough to be
spontaneous and responsible enough to be appropriate” (p. 660). Such an
injunction, he notes, engages a variety of mental processes: open expres-
sion of wants/needs; activation of conscience, values and belief systems;
executive functioning, judgment, and decision making. Furthermore, it
seems important to note that treatment is never a simple solution to any
problem and some difficulties are to be expected as a natural part of the
process. Patients may find that certain behaviors are difficult to change,
painful emotions may emerge, or they may become impatient with the pace
of treatment progress. Again these experiences are common to any treat-
ment promoting meaningful life changes, and patients should be encour-
aged to discuss these concerns with their treatment providers as they arise.
Finally, treatment preparation involves informing patients about what
their therapists will (or will not) be doing to aid their work together. For
example, Luborsky (1984) cautions that the therapist is not in the practice
of doling out advice, that “it’s the therapist’s job not to give advice but to
help you find out for yourself how you are going to solve your problems”
(p. 194). Whether this involves tracing links contributing to maladaptive
behaviors, identifying and altering irrational cognitive processes, discussing
events that occur within the context of the treatment relationship, or
examining repetitive maladaptive relational patterns across time, it falls to
the therapist to inform the patient about what techniques are typical of
180 DeFife and Hilsenroth
their treatment practice as well as their conceptions of how those treatment
techniques are designed to influence therapeutic change. To optimize this
process, therapists and patients need to work together to conceptualize the
types of treatment changes desired while collaborating on the methods
provided toward achieving those goals.
GOING FOR THE GOALS
Opening up a discussion of the chief concerns leading someone to seek
treatment and identifying what types of changes are desired paves the way
toward a collaborative formulation of reasonable treatment goals. Bordin
(1979) identified three major features of a working alliance including
agreement on goals, assignment of tasks, and the development of patient-
therapist bond. Though his concepts have been supplemented with other
factors of therapeutic alliance, Bordin’s factors of goal-task agreement and
therapeutic bond remain firmly imbedded in current conceptualizations
and measurement instruments of therapeutic alliance (Bordin, 1994;
Hatcher, 1999; Hatcher & Barends, 1996; Horvath, 2001). Orlinsky, Grawe,
and Parks (1994) note that contractual “clarity and consensus tend to be
important factors when assessed from the patient’s perspective or by means
of an objective index, but curiously irrelevant from the therapist’s process
perspective” (p. 282). Their findings generate reasonable concerns about
the amount of collaborative goal setting performed in real-world practice.
If a therapist perceives no discernable outcome effects from the collabor-
ative formulation of an explicit treatment contract, this process may be
overlooked in the crucial early periods of psychotherapy, eliminating a
valuable aspect of the patient’s therapeutic experience.
In their review of psychotherapy research on goal consensus and
collaboration, Tryon and Winograd (2002) identify the relationship of a
therapist actively providing information to and collaboratively engaging
with his or her patient to the patient’s return following the intake or initial
psychotherapy session. As they note, attendance after initial therapeutic
contact is not viewed as a therapeutic outcome in and of itself, but (aside
from being essential for the continuation of the therapeutic work) is a
critical early benchmark to achieve. In a meta-analysis of 125 studies across
diverse treatment settings, Weirzbicki and Pekarik (1993) found a psycho-
therapy dropout rate of 46.86% of patients. Not only has it been argued
that “the largest percentage of clients that drop out of therapy do so after
one session” (Odell & Quinn, 1998, p. 369; Phillips, 1987), but also that
patients who return after the initial therapeutic contact tend to stay in
treatment until an agreed upon termination date (Tryon, 1985; Tryon &
Tryon, 1986). Tracy (1977) highlighted the importance of the therapist
181Common Factors in Early Treatment
establishing a collaborative relationship and goal consensus during the
intake evaluation; investigating two models of intake interview revealed
that significantly more patients returned following interviews in which their
problems were formulated and treatment goals were negotiated. A later
study also showed that significantly more patients returned for treatment
following intake sessions in which therapists rated their own intake behav-
ior as more focused on explicitly identifying and clarifying the presenting
problems with their patients (Tryon, 1989).
Tryon and Winograd (2002) further reviewed studies examining the
relationship of goal consensus and collaboration with outcome starting by
looking at immediate session effects. Eisenthal et al. (1983) obtained
observer ratings of mutuality of treatment decision making and clarity of
therapist communications of rationale from audiotaped sessions of intake
interviews. Patient ratings of intake session satisfaction were related to
both factors of goal negotiation and clarity of the therapists’ explanatory
processes. Furthermore, neither goal negotiation nor therapist clarity as
measured by the external raters was related to therapist ratings of session
satisfaction or therapist perception of their patient’s satisfaction with the
session. The authors concluded that initial interview outcomes may be
negatively impacted by divergences in therapist valuation of certain inter-
view processes and by therapist misperceptions of patient satisfaction.
These findings highlight the significance of early interactive role-goal ne-
gotiation and psychoeducational clarity as processes important to patients
entering psychotherapy, an importance that may be overlooked by their
therapists. These processes may not only impact client satisfaction, but also
a subjective sense of well-being: for example, therapist agreement on goals
and responsiveness to patient requests during an intake session was posi-
tively associated with reductions in postintake distress levels in a hospital
crisis center sample (Kirk, Stanley, & Brown, 1988). Session effects from
goal discussion are found not only at intake, but also in subsequent
sessions. Two studies found observer ratings of “goodness” of sessions
from short-term psychodynamic psychotherapy positively related to inde-
pendent ratings of therapeutic actions focused on goal discussion (Hoyt,
1980; Hoyt et al., 1983): again, the same therapeutic actions were not
related to therapists’ ratings of “good” sessions (Hoyt et al., 1983), further
supporting the notion that therapeutic activities viewed as beneficial or
even essential to patients’ well-being may be overlooked in clinicians’
beliefs about change processes.
Tryon and Winograd (2002) note that patient-therapist goal consensus
ratings have also been examined for the prediction of global therapeutic
outcome, though with mixed results. Paivio and Bahr (1998) obtained
patient rated Goal Agreement scale scores from the Working Alliance
Inventory (WAI; Horvath & Symonds, 1989) after the third and final
182 DeFife and Hilsenroth
sessions of a 12-session experiential psychotherapy. Only one relationship
with outcome from the obtained Goal Agreement scores reached signifi-
cance: Goal Agreement scores procured at the conclusion of treatment
were negatively related to change scores of an author-created measure of
unresolved relational issues. Perhaps the negative correlation found in the
Paivio and Bahr study may be explained in that high Goal Agreement
scores obtained at the conclusion of treatment suggest that both patient
and therapist recognize the presence of salient maladaptive relational
issues still needing to be addressed, thus counterindicating termination at
that point.
Other studies have found positive relationships between early ratings
of goal consensus and global therapeutic outcomes using diverse measures
in a range of treatment samples. In a Dutch outpatient sample, patient
ratings of agreement with the therapist as well as ratings of experienced
goal consensus following the second session of psychotherapy were pre-
dictive of patient and therapist ratings of symptom reduction as late as
6-months after the beginning of treatment (Dormaar et al., 1989). In a
sample of couples receiving brief therapy (Quinn et al., 1997), wives’, but
not husbands’, ratings of goal consensus after the third session were
positively correlated with their final ratings of treatment outcome. Pre-
treatment ratings of patients’ commitment to therapeutic goals were pos-
itively related to remission of bulimic symptoms in patients about to
receive a 12-session cognitive–behavioral group therapy for bulimia (Mus-
sell et al., 2000). Even in inpatient settings, patient participation in elabo-
rating treatment goals is related to goal involvement as well as treatment
outcome (Evans, 1984; Willer & Miller, 1976).
Even with a collaborative goal setting process, goal disagreement can
occur. Three studies utilizing the Goal Disagreement scale of the California
Psychotherapy Alliance Scales (CALPAS; Marmar et al., 1986) provide
mixed results in assessing the relationship of goal consensus with depres-
sion symptom reduction. Across three types of treatment (cognitive, be-
havioral, and brief dynamic therapy) completed within 16 –20 sessions,
Beck Depression Inventory (BDI; Beck et al., 1961) change scores were
not significantly predicted by Goal Disagreement scores obtained after the
5th session (Marmar et al., 1989). A replication and extension of the
Marmar et al. study yielded no significant prediction of BDI measured
symptom reduction from Goal Disagreement ratings obtained after the 5th,
10th, and 15th sessions of psychotherapy (Gaston et al., 1991). However,
Safran and Wallner (1991) found that patient-rated CALPAS Goal Dis-
agreement scores obtained after the third session of a 20-session cognitive
therapy for depression were significantly predictive of depression symptom
reductions as measured by the BDI and the Millon Clinical Multiaxial
Inventory (Millon, 1983) at termination.
183Common Factors in Early Treatment
The importance of early therapeutic contract negotiation is further
highlighted in an examination of factors related to drop-out in the treat-
ment of patients with Borderline Personality Disorder (BPD; Yeomans et
al., 1994). Noting that BPD patients are characterized by a particularly high
drop-out rate, the study demonstrated that external ratings of therapists’
contributions to and skills in formulating a collaborative treatment contract
related to the duration that patients remained in treatment. Utilizing a
treatment contract as part of a structured clinical treatment model, the
study produced a substantially reduced drop-out rate (17% by the third
session, 36% by 6 months) and further demonstrated that the therapist’s
skill in discussing the treatment contract was an important factor in deter-
mining the patient’s length of stay in treatment, independent of therapeutic
alliance rating.
Clearly, the inclusion of patient feedback during collaborative goal
formation is fundamental during the early stages of the therapeutic process.
Therapeutic activities geared toward collaborative goal setting, the impor-
tance of which may be overlooked in clinicians’ views of essential change
elements, contribute to patients’ return to treatment after intake, subjec-
tive sense of well-being, and the experiential quality of their treatment
sessions. The relationship of goal consensus ratings obtained beyond the
third session of treatment to global therapeutic outcome is not firmly
established. Given the time-limited structure of treatments found in many
of the above mentioned psychotherapy process-outcome studies, high goal
agreement scores obtained later in treatment may signal the presence of
treatment issues that may be left unresolved in briefer therapies; high goal
agreement scores at the end conclusion of a brief therapy may suggest that
both patient and therapist feel that there are significant therapeutic goals to
be achieved through further treatment. Nonetheless, these findings
strongly suggest that goal setting activities and patients’ felt contribution
and understanding within a collaborative goal setting process have positive
overall effects on patients’ experiences of the therapeutic relationship.
Indeed, the experience of mismatch was labeled as a significant hindering
factor in a qualitative study of patients’ perceptions of curative factors in
psychotherapy (Lilliengren & Werbart, 2005). The mismatch factor de-
scribed in the Lilliengren and Werbart study covers a range of patient
concerns such as disagreement on treatment modality, feelings of discon-
nection from the therapist, and incongruence of therapeutic roles and
goals.
With an open dialogue about the concerns bringing someone into
treatment, treatment goals can be identified and a technical scheme to
achieve these goals can be developed. Treatment goals (and some exam-
ples) can: be short-term (return to a regular sleep schedule) or long-term
(maintain medication compliance even after periods of symptomatic im-
184 DeFife and Hilsenroth
provement); cover wide domains of functioning (increase occupational
satisfaction; increase contact with community activities; decrease social
isolation); be specific (decreased frequency of a specific compulsive behav-
ior, identification of a recurrent problematic relational theme) or general
(increased family cohesion, greater feelings of intimacy and stability in
relationships). Another important piece of the goal negotiation process is
the question of how will progress toward these goals be measured? Prog-
ress may be recorded formally (e.g., with diagnostic criteria or formal
symptom measures) or through patient and therapist observations. Once
treatment goals are set, they should be reviewed periodically. While much
has been written on the concepts of conflict, resistance, defense, rupture,
and stalemate, it is vital to recognize and reinforce positive therapeutic
progress with patients. This can be accomplished through discussion of
coping strategies, thoughts, or behaviors that lead to positive affect, sub-
jective sense of well-being, or prosocial functioning. As treatment pro-
gresses, comparisons and contrasts can be made between current and past
modes of functioning.
CONCLUSION
Starting treatments off on the right foot creates the development of
mutual, collaborative, and fulfilling treatment relationships that will in turn
promote meaningful and lasting life changes. This review follows a com-
mon factors approach to psychotherapy integration through identifying
research evidence and suggesting practice implications for three major
factors at play during the crucial early phase of treatment including fos-
tering realistic and positive expectancies, role preparation for treatment,
and collaborative goal setting (for summary, see Table 1).
A common factors approach is one of the main routes to psychother-
apy integration (Arkowitz, 1989). By identifying the core therapeutic in-
gredients that are effective across different forms of psychotherapy (Frank,
1961/1973), therapists can more actively focus on facilitating those methods
as agents of change. The advantage of this approach is to capitalize on
therapeutic elements with demonstrated efficacy while still allowing the
therapist to work within their practiced, grounding framework.
Hubble, Duncan, and Miller (1999; Miller, Duncan, & Hubble, 2005)
suggest that successful treatment arises less from a therapist-driven model
and more from adopting the client’s frame of reference as a defining theory
of the psychotherapy. Such a perspective, they argue, fits empirical findings
demonstrating that “the quality of the client’s participation in treatment
stands out as the most important determinant of outcome” (Orlinsky et al.,
185Common Factors in Early Treatment
1994, p. 361). Yet a question remains as to what methods are most effective
for engaging the patient as an active “copilot” in the treatment situation.
Given that psychotherapy process research is typically correlational in
nature, causal inferences between process elements and subsequent out-
come often cannot be asserted with certainty. Furthermore, it is difficult to
generalize across clinical populations as some of the suggested clinical
techniques may be more difficult to implement in certain cases. Research
should continue to work on identifying the subsequent effects of treatment
techniques geared toward fostering positive expectancies, role preparation
and goal collaboration in treatment. In addition, studies might examine
outcomes related to the training of practitioners in techniques aimed at
achieving these factors. It falls to clinicians to utilize the best available
research evidence in their endeavors toward effective patient care.
There is no “one-size-fits all” approach to meeting how individuals
relate and would like to be related to (Duncan & Miller, 2000). As such, no
circumscribed technical approach will match everyone’s individual needs.
At crucial moments early in the therapeutic process, therapists can tran-
scend the constraints of discrete treatment models by engaging the patient
as an active collaborator through soliciting their treatment expectancies,
Table 1. Summary of Early Treatment Stage Principles and Techniques Contributing to
Positive Therapeutic Outcome
Fostering positive expectancies
Develop a plausible rationale or conceptual scheme for symptoms
Utilize qualities and techniques designed to enhance the therapeutic relationship (e.g.,
flexibility, alertness, honesty, accurate interpretation, and fostering affective
expression)
Identify an explicit treatment course geared at alleviation of problems
Engender confidence in the treatment process (e.g., invoke evidence and experience
for treating patient concerns)
Identify commitment to the therapeutic relationship and process
Normalize patient concerns
Role preparation
What is the treatment frame? (e.g., length, duration, frequency, fee)
What is the patient’s role in treatment?
What activities are they suggested completing?
What types of content should they expect to focus on?
What will the therapist contribute to the process? (e.g., What is the treatment rationale
for how techniques will contribute to treatment change?)
Collaborative goal formation
Clarify concerns leading patients to seek treatment
Identify short-term and long-term goals
Identify goals across a range of functioning
Develop a method for assessing treatment changes over time
Regularly review progress towards treatment goals
Highlight adaptive changes
Identify areas for continued growth
Compare and contrast current and past functioning
186 DeFife and Hilsenroth
preparing them for an active role in treatment, and constructing therapeu-
tic goals together. Clinical indications suggest that an initial phase of
remoralization occurs when patients feel heard and understood in an
environment where they are encouraged to discuss their current concerns
and priorities in life. Together, the patient and therapist begin to shape a
plausible formulation in which symptoms can often be identified as non-
optimal attempts at problem resolution and normalized through their
commonalities to others with similar concerns. With this formulation de-
veloped, commitment to the treatment relationship is expressed and a
treatment is prescribed with confidence gained from evidence and experi-
ence. Patients are then prepared for this treatment by a discussion of frame
issues, suggestions of what they may bring to and talk about during
treatment sessions, and a negotiation of therapeutic techniques designed to
elicit change. Short-term and long-term treatment goals are collaborated
on and targeted at both specific symptom-level changes as well as broad
quality of life improvements. Finally, a system is developed in which these
treatment goals are to be assessed and periodically reevaluated for prog-
ress.
Such an approach is not meant to supplant specific technical ap-
proaches to facilitating therapeutic change. Specific treatment effects con-
tribute incrementally to treatment outcome measurements, especially in
cases of greater degrees of diagnostic severity (Stevens, Hynan, & Allen,
2000). However, fostering positive treatment expectancies, role
preparation, and goal collaboration fall in the domain of common factors
of treatment that have been identified through prior research as effective
therapeutic elements occurring across multiple psychotherapy modalities.
Techniques capitalizing on these research findings should be considered
beneficial foundational elements to any integrative therapeutic endeavor,
setting the groundwork for significant and meaningful treatment change.
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