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Expanding the Lens of Evidence-Based Practice in Psychotherapy: A Common Factors Perspective

  • University of Wisconsin--Madison and Modum Bad, Norway

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In this article, we examine the science and policy implications of the common factors perspective (CF; Frank & Frank, 1993; Wampold, 2007). As the empirically supported treatment (EST) approach, grounded in randomized controlled trials (RCTs), is the received view (see Baker, McFall, & Shoham, 2008; McHugh & Barlow, 2012), we make the case for the CF perspective as an additional evidence-based approach for understanding how therapy works, but also as a basis for improving the quality of mental health services. Finally, we argue that it is time to integrate the 2 perspectives, and we challenge the field to do so. (PsycINFO Database Record (c) 2013 APA, all rights reserved).
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Expanding the Lens of Evidence-Based Practice in Psychotherapy:
A Common Factors Perspective
Kevin M. Laska
Bedford VA Medical Center, Bedford, Massachusetts Alan S. Gurman
The Family Institute at Northwestern University and
University of Wisconsin-Madison
Bruce E. Wampold
University of Wisconsin-Madison and Modum Bad Psychiatric Center, Vikersund, Norway
In this article, we examine the science and policy implications of the common factors perspective (CF;
Frank & Frank, 1993;Wampold, 2007). As the empirically supported treatment (EST) approach,
grounded in randomized controlled trials (RCTs), is the received view (see Baker, McFall, & Shoham,
2008;McHugh & Barlow, 2012), we make the case for the CF perspective as an additional evidence-
based approach for understanding how therapy works, but also as a basis for improving the quality of
mental health services. Finally, we argue that it is time to integrate the 2 perspectives, and we challenge
the field to do so.
Keywords: empirically supported treatments, evidence-based practice, common factors, outcomes,
Dr. Brown, the director of an outpatient mental health clinic, is
staying late to prepare for tomorrow’s annual staff retreat. She is
faced with multiple challenges including a growing demand for
psychotherapy services and a reduced budget, and because the
clinic was recently approved as an APA-accredited internship site,
she also faces the challenge of how to train the next generation of
psychologists in “evidence-based practice (EBP).” She decides to
pose this question to her staff: what does the research evidence say
about providing effective psychotherapy and, specifically, how can
we cost effectively apply this knowledge in our setting to improve
the quality of care?
In the example above, Dr. Brown asks her staff to think criti-
cally about providing EBP. A reasonable request, but what exactly
is EBP? It appears that on this matter there is much confusion for
students, psychologists, and consumers of psychotherapy alike.
For example, in a recent survey of clinical psychology graduate
students, the majority identified EBP as synonymous with empir-
ically supported treatments (ESTs) (Luebbe, Radcliffe, Callands,
Green, & Thorn, 2007). Similar results conflating EST and EBP
have been found among practicing psychologists (American Psy-
chological Association Presidential Task Force on Evidence-Based
Practice, 2006;Pagoto et al., 2007;Wachtel, 2010;Westen, No-
votny, & Thompson-Brenner, 2005). The same mistake has also
appeared in newspaper articles that have portrayed anything other
than ESTs as “art,” thereby painting the picture that clinicians not
providing ESTs are resistant to EBP (Brown, 2013,The New York
Times, p. D4). Clearly some clinicians are ambivalent toward some
aspects of EBP (see Lilienfeld, Ritschel, Lynn, Cautin, & Latzman,
2013). Yet, we believe the prioritization of randomized controlled
trials (RCTs) and ESTs over the last few decades has unintention-
ally limited the scope of EBP and may have ironically worked
against the central purpose of psychotherapy research, that is, the
improvement of practice, by limiting the variety of evidence
deemed relevant to such an aim.
In this article, we argue that a primary reason EBP has been
conflated with EST, and therefore has been somewhat limited in
application, is that the scientific exploration of therapeutic factors
other than treatment methods have been discouraged or labeled as
“unscientific.” For example, according to Chambless & Crits-
Christoph, (2006):
Of all the aspects of psychotherapy that influence outcome, the treatment
method is the only aspect in which psychotherapists can be trained, it is
the only aspect that can be manipulated in a clinical experiment to test its
worth, and, if proven valuable, it is the only aspect that can be dissemi-
nated to other psychotherapists (p. 199, emphasis added).
Or, as Baker et al. (2008) noted:
Research on nonspecific effects [that is, aspects of the CF approach]
provides little support for the current practices of psychology, however.
Legitimate and important issues surround nonspecific effects, but the
resolution of the debate about nonspecific effects has little potential to
validate a science-based practice of clinical psychology....
This article was published Online First December 30, 2013.
Kevin M. Laska, Bedford VA Medical Center, Bedford, Massachusetts;
Alan S. Gurman, The Family Institute at Northwestern University, and
Department of Psychology, University of Wisconsin-Madison; Bruce E.
Wampold, University of Wisconsin-Madison, and Modum Bad Psychiatric
Center, Vikersund, Norway.
Dr. Alan S. Gurman sadly passed away during the completion of this
manuscript. We dedicate this work to him.
Correspondence concerning this article should be addressed to Kevin M.
Laska, Bedford VA Medical Center, Bedford, MA 01730. E-mail:
This document is copyrighted by the American Psychological Association or one of its allied publishers.
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
Psychotherapy © 2013 American Psychological Association
2014, Vol. 51, No. 4, 467–481 0033-3204/14/$12.00 DOI: 10.1037/a0034332
It is important to note the marginal scientific status of those constructs
(p. 82, emphasis added).
As discussed by philosophers of science, notably Kuhn (1962),
restricting the lens through which a phenomenon is examined (in
this case, psychotherapy) restricts what can be observed and the
manner in which “evidence” is interpreted. In other words, a
restricted scientific aperture means less of the evidentiary picture
is in focus.
The result is that the application of EBP toward the reduction of
mental illness is limited. The primary strategy for quality improve-
ment in mental health today is to implement ESTs in clinical
practice (McHugh & Barlow, 2012). A straightforward and per-
suasive case has been made that ESTs that have been shown to be
efficacious in clinical trials should be disseminated widely and
used (Baker et al., 2008). We agree that disseminating ESTs into
practice settings should be one arm of a multifaceted “portfolio”
approach (Kazdin & Blasé, 2011) toward reducing the burden of
mental illness. We are not arguing that the field should discard the
use of ESTs. Yet, substantial evidence from other perspectives of
EBP, including the common factors (CF) approach, are frequently
marginalized as “unscientific,” or are given such low evidentiary
prioritization that important data are overlooked. The result is that
our ability to maximize practice outcomes has been limited.
Our purpose here is to expand the scientific understanding of the
received EST view and broaden the lens through which observa-
tions about psychotherapy are interpreted. According to the APA’s
Presidential Task Force on Evidence-Based Practice (2006):
ESTs start with a treatment and ask whether it works for a certain
disorder or problem under specified circumstances. EBPP starts with
the patient and asks what research evidence (including relevant results
from RCTs) will assist the psychologist in achieving the best outcome
(p. 273).
Notably, the Task Force criteria highlight the importance of
clinical expertise and patient characteristics as central factors in
EBP, similarly to the definition of evidence-based medicine (In-
stitute of Medicine, 2001), and “builds on the Institute of Medicine
definition by deepening the examination of clinical expertise and
broadening the consideration of patient characteristics” (p. 273).
The Task Force criteria acknowledge these factors exist within
“the limits of one’s knowledge and skills and attention to the
heuristics and biases—both cognitive and affective—that can af-
fect clinical judgment” (p. 284). Yet, some have characterized the
Task Force’s inclusion of therapist and patient variables as “a
striking embrace of a prescientific perspective” (Baker et al., 2008,
p. 84). Although it may be “prescientific” for clinicians to uni-
formly disregard research evidence of any kind (as some small
minority do), it is decidedly and unequivocally not “prescientific”
for clinicians to approach the results of RCTs as only one of
several components of research evidence. We argue that this
rhetoric that explicitly devalues the role of other variables, includ-
ing therapist variables and client preference, and that in practice
effectively renders other types of evidence (e.g., process-outcome,
qualitative, meta-analytic) as tertiary in quality improvement ef-
forts, is not consistent with APA’s definition of EBP, and limits
the impact of EBP in clinical settings.
We believe the CF perspective is entirely consistent with the
APA’s outcome-focused approach toward EBP. The CF approach
asserts that (a) most therapists achieve commendable and desirable
outcomes, (b) improvement will flow from managing outcomes,
(c) any variable shown to influence outcome is scientifically
important, and therefore (d) data-gathering efforts should focus on
changing any therapist behaviors that influence outcome. We
begin with a brief review of the core predictions of both the EST
and CF approaches. Next, we review the evidence in context,
paying particular attention to some overlooked aspects of the EST
approach. Finally, we address how both programs approach quality
improvement and argue that the two perspectives should be inte-
The EST Approach
The EST approach proposes that psychotherapeutic treatments
contain specific techniques that are purported to remediate identi-
fiable deficits that form the diathesis of a given mental disorder
(Barlow, 2004;Chambless & Hollon, 1998;Chambless et al.,
1996). As described by Barlow (2004), ESTs also contain a variety
of components common to all psychotherapies, such as “the ther-
apeutic alliance, the induction of positive expectancy of change,
and remoralization,” but contain important “specific psychological
procedures targeted at the psychopathology at hand” (p. 873).
Similarly, Baker et al. (2008), in their comments on clinical
science, constrained the scientific focus to these specific ingredi-
Scientific plausibility refers to the extent to which an intervention
makes sense on substantive bases and whether there is formal evi-
dence regarding its mechanisms . . . . However, the absence of a
demonstrated or plausible specific mechanism of action, especially for
a psychosocial intervention, leaves open the possibility that the inter-
vention may merely be capitalizing on nonspecific credible ritual, or
placebo effects (emphasis added, p. 72).
Each EST posits a specific mechanism of change based on a
given scientific theory. For example, prolonged exposure (PE) for
PTSD (Foa, Hembree, & Rothbaum, 2007) is conceptually derived
from emotional processing theory (Foa & Kozak, 1986), and the
specific ingredients of PE (viz., imaginal and in vivo exposure) (a)
activate the “fear network,” (b) whereby clients habituate to their
fears, and thus, (c) extinguish the fear response. On the other hand,
interpersonal therapy (IPT) for PTSD (Markowitz, Milrod,
Bleiberg, & Marshall, 2009) is derived from interpersonal and
attachment theory (Bowlby, 1973;Sullivan, 1953) and “focuses on
current social and interpersonal functioning rather than exposure”
(Bleiberg & Markowitz, 2005, p. 181). Alternatively, when com-
paring Acceptance and Commitment Therapy (ACT; Hayes, Stro-
sahl, & Wilson, 2012) and Cognitive Behavioral Therapy (CBT;
Beck, Rush, Shaw, & Emery, 1979), two common ESTs for
depression, experts in these treatments described these therapies as
“distinct models” (Hayes, Levin, Plumb, Villatte, & Pistorello,
2011, p. 16) that “show substantial differences in their philosoph-
ical foundations” (Hofmann & Asmundson, 2008, p. 12). Different
ESTs are based on different theories of change, and purport dif-
ferent mechanisms of action.
More recently, researchers have identified common symptoms
within a class of disorders (e.g., mood and anxiety), and have
begun to develop various “unified treatment protocols” (Moses &
Barlow, 2006). We believe transdiagnostic treatments are a posi-
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tive development, and in fact, overlap with various aspects of the
CF approach. Yet, the specifications of methodologies—that is,
rules that dictate how science is conducted—remain within the
EST paradigm, for example, RCTs of treatment packages based on
identifying specific ingredients are given top evidentiary prioriti-
There are two core EST predictions: (a) treatment specificity
and (b) disorder specificity. In terms of treatment specificity,
because two treatments target different mechanisms of change, the
conjecture is that one treatment will be more efficacious than the
other. That is, under the correct conditions, there will be sufficient
evidence to reject the null hypothesis of no differences. Alterna-
tively, some researchers may conduct equivalence trials to show
that a new treatment is as effective as a standard treatment (e.g.,
Arch et al., 2012;Resick, Nishith, Weaver, Astin, & Feuer, 2002).
Regarding disorder specificity, the conjecture is that one treatment
will be more effective than another for treating a particular symp-
tom of a disorder, e.g., “In this case, a treatment T1 may be more
efficacious than T2 for treating symptoms S1 but not for treating
symptoms S2.” (Hofmann & Lohr, 2010, p. 14).
The CF Approach
The CF approach (Frank & Frank, 1993;Wampold, 2001)
conceptualizes psychotherapy as a socially constructed and medi-
ated healing practice. The CF model focuses on factors that are
necessary and sufficient for change: (a) an emotionally charged
bond between the therapist and patient, (b) a confiding healing
setting in which therapy takes place, (c) a therapist who provides
a psychologically derived and culturally embedded explanation for
emotional distress, (d) an explanation that is adaptive (i.e., pro-
vides viable and believable options for overcoming specific diffi-
culties) and is accepted by the patient, and (e) a set of procedures
or rituals engaged by the patient and therapist that leads the patient
to enact something that is positive, helpful, or adaptive. Whereas
EST places primacy on different theories of change, a CF approach
states that the adoption of a credible theory is only one aspect of
many necessary common factors that contribute to behavior
There are a few core predictions of the CF approach. The first
is that any therapy that contains all of the ingredients of the CF
approach (as outlined above) will be efficacious for the presenting
problem being treated. As Lambert recently noted, “. . . studies
comparing two bona fide therapeutic approaches that find signif-
icantly different outcomes may be more unusual than not” (2013a,
p. 196). A second prediction is that relationship factors such as
empathy, goal consensus and collaboration, the therapeutic alli-
ance, and positive regard, should predict the outcome of psycho-
therapy. A corollary of this second prediction is that there will be
differences among therapists, that is, more effective therapists will
more skillfully provide these factors. A third prediction is that
treatments intended to be therapeutic will be superior to “support-
ive control” or psychological placebo conditions.
We wish to briefly identify five common misunderstandings of
the CF approach. First, it is important to note that the CF perspec-
tive does not suggest that a mere “relationship” with a therapist is
sufficient, as some have (mis)interpreted. As noted above, the
therapeutic alliance should predict outcome, but the alliance is
only one factor of several that are necessary from a CF perspective.
Second, “supportive counseling” is not synonymous with CF.
Typically, these treatments, elsewhere referred to as “intent-to-
fail” treatments (Westen, Novotny, & Thompson-Brenner, 2004),
are used to control for the common factors in RCTs. Many “sup-
portive counseling” treatments contain no psychologically derived
rationale or proscribe therapists from actions that most therapists
would normally use, particularly when the therapists in these
conditions know that the treatment is a sham (Budge, Baardseth,
Wampold, & Flückiger, 2010). For example, in a trial comparing
CBT and supportive psychotherapy for PTSD related to motor
vehicle accidents (Blanchard et al., 2003), therapists delivering
supportive therapy provided “little advice” and “care was taken not
to encourage any driving. If the participant asked directly about a
specific travel behavior, he or she was told to listen to his or her
body and be guided by how he or she felt” (p. 86). Third, the term
“bona fide,” as theoretically derived from CF theory and opera-
tionalized by Wampold et al. (1997), has been largely (mis)under-
stood and incorrectly applied. For example, Hofmann and Smits
(2008), included supportive counseling, relaxation treatments, and
anxiety management as bona fide therapies in their meta-analysis
of adult anxiety disorders, although these treatments were not bona
fide treatments (i.e., did not meet the operationalized criteria
outlined in Wampold et al., 1997). Similarly, Ehlers et al., (2010),
critiqued the results of Benish, Imel, and Wampold (2007) based
on incorrect assumptions of bona fide therapies (see Wampold et
al., 2010 for response to Ehlers). Fourth, a “common factors
treatment” that some have argued is necessary for a valid test of
specific versus common factors (Barlow, 2010;Foa, 2013) over-
looks the important point that the CF approach states that any
therapy with all CF ingredients will be efficacious. Lastly, under
the CF approach, therapists cannot simply do whatever they want,
however they want, and for as long as they want. The CF approach
is focused on improving practice outcomes and therapist compe-
tence. Achieving this aim requires a variety of evidence-based
techniques, which we address later in this article, that encourage
therapists to adjust their practices in specific ways and not practice
without purpose.
The evidence related to ESTs has been summarized elsewhere
(Baker et al., 2008;Barlow, 2008;Foa, 2013;Lilienfield et al.,
2013), as has the evidence related to the CF approach (Imel &
Wampold, 2008;Wampold, 2001,2007). In this section, we focus
on several aspects of the EST perspective that we believe have
been overlooked, as well as evidence for the CF approach that is
often criticized by proponents of ESTs.
The Post Hoc Issue
We claim that ESTs researchers resort to inconsistently applied
post hoc explanations when observations are not consistent with
core EST predictions. The result is not falsification of ESTs, but a
reduction in the explanatory power of treatment specificity. We
review several examples below, focusing on the issue of treatment
In a large sample of therapists in the National Health Service in
England, Stiles and colleagues (Stiles, Barkham, Mellor-Clark, &
Connell, 2008;Stiles, Barkham, Twigg, Mellor-Clark, & Cooper,
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2006) found no differences in outcomes among therapists who
indicated they were practicing cognitive–behavioral, person-
centered, and psychodynamic therapies. However, Clark, Fairburn,
and Wessely (2007) criticized the studies on the basis that the
therapists who indicated that they were practicing CBT were not
actually doing so, at least to the degree necessary to reveal that this
treatment was superior. In a 1999 study, Tarrier et al. (1999)
compared imaginal exposure (IE) with cognitive therapy (CT) and
concluded, “A significantly greater number of patients receiving
IE worsened over treatment” (p. 17) compared with CT. However,
Devilly and Foa (2001) claimed that Tarrier et al. delivered IE
inappropriately, “Did the therapist note ‘hot spots’ where appro-
priate and habituate the participants to these?” (p. 115). One does
not have to venture far into the literature to find other examples
where a result is impugned post hoc regarding issues of adherence.
This is what might be called the adherence hypothesis: differences
will be detected provided the treatment is delivered in the specified
manner (Perepletchikova, Treat, & Kazdin, 2007). Indeed, this
conjecture is of such importance that Suris, Link-Malcolm, Chard,
Ahn, and North (2013) found that one therapist failed to adhere to
the treatment protocol and eliminated the data for that therapist
from the trial. This issue is problematic for a number of reasons.
First, it is often used post hoc to explain the lack of treatment
differences, but also to protect particular treatments from being
identified as inferior, which then renders the EST prediction as less
heuristically powerful. Concordantly, meta-analytic findings sug-
gest that adherence in delivering a treatment is not related to
outcome (Webb, DeRubeis, & Barber, 2010), although the
adherence-outcome correlation needs further scrutiny (Leichsen-
ring et al., 2011).
In an example of null findings, Ehlers et al. (2010) attributed the
lack of differences between CBT and present-centered therapy
(PCT) found by McDonagh et al. (2005) and Schnurr et al. (2003)
to the fact that the patients in these trials belonged to “difficult to
treat multiple trauma populations” (p. 271), an explanation that
was not mentioned by the authors of the primary studies and more
importantly was not stated a priori. Even when rated adherence to
both treatments is sufficient, as it was in a comparison of behav-
ioral marital therapy (BMT) and insight-oriented marital therapy
(IOMT) that found that IOMT had significantly fewer divorces
after therapy (Snyder, Wills, & Grady-Fletcher, 1991), an advocate
for the inferior treatment (BMT) invoked a post hoc explanation.
Jacobson (1991) claimed that therapists in the BMT condition did
not sufficiently provide empathy and emotional nurturance and did
not adequately foster hope, actions that were not specific to the
treatment; that is, there was purportedly an inequivalence of
the CF. Interestingly, the most rigorous RCT ever conducted (viz.,
the National Institute of Mental Health Treatment of Depression
Collaborative Research Program) in its time could not inoculate
the results against claims that a treatment was at a disadvantage for
some reason (Elkin, Gibbons, Shea, & Shaw, 1996;Jacobson &
Hollon, 1996).
Discussion of these factors should not be taken as criticism ipso
facto, as every scientific investigation has some flaws (Cook &
Campbell, 1979). All observations naturally come with baggage
owing to particular experimental arrangements (Serlin & Lapsley,
1985). Nevertheless, a theory must be able to generate a conjecture
that results in certain observations under specified conditions.
Therefore, it can be argued that invoking explanations post hoc by
a treatment advocate to protect a treatment from being found
inferior is simply “partisan politics” and should not be taken
seriously as science. However, science is a community project and
if such explanations are invoked in scientific journals they become
part of the scientific discourse, particularly when it is EST scien-
tists who are invoking such explanations.
We believe CF explains these issues, and in this regard has equal
(or possibly greater) heuristic power. The CF approach posits that
specific ingredients are not necessary, and therefore post hoc
explanations are not needed because null results have been pre-
dicted. When treatment differences are found, post hoc explana-
tions are also not needed because CF predicts that over the corpus
of results, some treatment differences will be found by chance.
Is One Treatment More Effective Than
Another Across All Disorders?
According to the APA Resolution on Psychotherapy Effective-
ness, “comparisons of different forms of psychotherapy most often
result in relatively nonsignificant difference, and contextual and
relationship factors often mediate or moderate outcomes (APA,
2013, p. 103).” We concur with APA’s interpretation of the evi-
dence (however, see Hunsley & Diguilio, 2002;Siev, Huppert, &
Chambless, 2009 for counterargument). As noted above, EST
predicts that some treatments will be more effective than other
treatments, which is the logical opposite of CF, which states that
all bona fide treatments are equally efficacious. The null hypoth-
esis of the EST prediction is exactly the null tested in meta-
analyses of direct comparisons of treatments (see Wampold et al.,
1997;Wampold & Serlin, 2014), thus providing a direct test of a
crucial aspect of these conjectures. Wampold et al. (1997) con-
ducted such a meta-analysis of nearly 300 direct comparisons of
treatments intended to be therapeutic and found insufficient evi-
dence to reject the null hypothesis. Although there were compar-
isons within this data set that resulted in rejection of the null (i.e.,
produced statistically significant differences), the number was
about equal to what would be expected by chance owing to
sampling error. Indeed, the observed aggregate effect was less than
what would be expected under the null, suggesting not a hint of an
effect (Wampold & Serlin, 2014). This meta-analysis had more
than adequate power to detect relatively small differences among
a small proportion of comparisons (Wampold & Serlin, 2014) and
therefore provides evidence that would seem to be in line with the
predictions of the CF perspective.
It was claimed that many of the comparisons in the Wampold et
al. (1997) meta-analysis were among variations of CBT treatments
and therefore not likely to yield differences (Crits-Christoph,
1997), an observation that generates many responses. First, typi-
cally researchers who posed the comparisons were attempting to
find differences that would demonstrate the importance of speci-
fied mechanisms of change. Therefore, under the EST prediction,
differences would be expected. Second, Wampold et al. (1997)
found that the similarity of the treatments being compared was not
related to the size of the effect (e.g., comparisons of treatments that
were different did not produce larger effects than did comparisons
of treatments that were similar). Third, regardless of the nature of
the comparisons, there is insufficient evidence to reject the null
hypothesis of no differences, a result that albeit tentative, must be
retained at this point in time. Fourth, several meta-analyses that
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have compared active treatments contain a wide variety of types of
treatments and many treatments other than CBT and have found no
differences (Benish et al., 2007;Cuijpers, van Straten, Andersson,
& van Oppen, 2008;Cuijpers et al., 2012;Imel, Wampold, Miller,
& Fleming, 2008;Powers, Halpern, Ferenschak, Gillihan, & Foa,
2010). As well, several meta-analyses have directly compared
CBT with other types of treatment and found no differences
(Baardseth et al., 2013;Leichsenring & Leibing, 2003;Shedler,
2010;Wampold, Minami, Baskin, & Tierney, 2002). One meta-
analysis (Tolin, 2010) did find that CBT was superior to other
treatments for depression and anxiety. This meta-analysis is dis-
cussed below.
From a CF point of view, which posits that there will be no
differences between treatments, Tolin appears to provide a refuta-
tion. But if dozens of meta-analyses finding no differences have
not refuted treatment specificity (as some have argued), then one
finding of such differences cannot refute the CF perspective.
There is more to be learned from the Tolin meta-analysis. The
effect size for depression for the superiority of CBT was small
(viz., 0.21) and only for symptom-specific measures (see Baards-
eth et al., 2013). Tolin’s effect for depression contradicts several
other meta-analyses that contained many more studies (Cuijpers et
al., 2008,2012;Wampold et al., 2002), and the effect was not
present for outcomes other than the symptom-specific measures
(Baardseth et al., 2013). The effect for the superiority of CBT for
anxiety was moderate (viz., 0.43), but was based on only four
studies, two of which were published before 1972. What is curious
here was that it appears that Tolin defined CBT broadly to contain
many treatments that many would argue are not CBT and are not
scientific (e.g., eye-movement desensitization and reprocessing,
EMDR; see Herbert et al., 2000;McNally, 1999), suggesting an
ambiguity with regard to CBT as well as other treatments. Con-
sequently, Baardseth et al. (2013) used an empirical definition of
CBT that relied on a consensus of experts from the Association for
Behavioral and Cognitive Therapies (ABCT) to determine what is
and is not CBT for anxiety disorders, and located 13 studies that
directly compared CBT with other treatments (vis-a
`-vis 4 for
Tolin), and found no differences between CBT and non-CBT
treatments for anxiety.
Is One Treatment More Effective Than Another for a
Particular Disorder?
Again we believe the evidence suggests “no.” A criticism of the
CF approach has been that it makes little sense to examine com-
parisons across disorders (e.g., DeRubeis, Brotman, & Gibbons,
2005). Ignoring disorder “is akin to asking whether insulin or an
antibiotic is better, without knowing the condition for which these
treatments are to be given...Alternatively, researchers should
begin with a problem and ask how treatments compare in their
effectiveness for that problem” (p. 175). When treatments are
directly compared, most have found no differences, including for
depression (Cuijpers et al., 2008,2012), alcohol use disorders
(Imel et al., 2008), PTSD (Benish et al., 2007;Powers et al., 2010),
anxiety disorders in general (Baardseth et al., 2013), eating disor-
ders (Spielmans et al., 2013), and childhood disorders (Miller,
Wampold, & Varhely, 2008;Spielmans, Pasek, & McFall, 2007).
There are notably few meta-analyses of direct comparisons that
have rejected the null. We have already reviewed Tolin. Another
showed that CBT was superior to relaxation therapy for panic
disorder (although the effect was due to one study—see Wampold,
Imel, & Miller, 2009).
By way of contrast, for the treatment of a small subset of
disorders, the CF model may have less explanatory power. For
example, in the case of specific phobia and panic disorder, and
possibly social phobia, evidence suggests improvement cannot
occur without exposure to the fearful stimulus taking place.
Whether exposure is accomplished in vivo, imaginally, via virtual
reality procedures or other methods (Antony & Roemer, 2011),
and whether exposure occurs intentionally within structured
manual-guided treatment sessions provided by a behavior therapist
or less systematically by, for example, risk-taking in everyday life,
exposure appears to be essential for these disorders (although
apparently not for other anxiety disorders, see Baardseth et al.,
2013;Frost, Laska, & Wampold, 2014). It is clear experiential
avoidance in some form must be addressed in therapy for some
anxiety disorders (Barlow et al., 2011;Hayes et al., 2012), as even
Jerome Frank, the originator of the CF perspective, agreed (Frank
& Frank, 1993). But we would argue that an inclusive EBP
approach would dictate that such decisions as with whom, at what
stage of change, and how systematically therapeutic exposure
might most helpfully take place, be left up to discussions between
therapist and client.
How Important Is the Alliance as a
Predictor of Outcome?
According to Baker et al. (2008), “In theory, some aspects of
nonspecific effects are malleable or teachable: for example, be-
haviors that contribute to the therapeutic alliance (the therapist–
patient relationship). Even these hold little promise that they
represent special opportunities for clinical psychology, however”
(emphasis added, p. 82). Most psychologists, including proponents
of ESTs, acknowledge the importance of the alliance. Yet, as
exemplified by Baker et al., may disagree on the relative impor-
tance of the alliance as a mediating variable. Here, we review the
evidence pertaining to the alliance–outcome relationship in hopes
to demonstrate the importance of this variable in improving EBP.
The therapeutic alliance is composed of three components: (a)
bond between therapist and patient, (b) agreement about the goals
of therapy, and (c) agreement about the tasks of therapy (Bordin,
1979) and is a central component of the CF program (Wampold,
2001;Wampold & Budge, 2012). The most recent meta-analysis,
based on hundreds of studies, reveals a robust and moderate
correlation (between .25 and .30) between the alliance and out-
come (Horvath, Del Re, Flückiger, & Symonds, 2011), although
this may be an underestimate owing to measurement issues (Crits-
Christoph, Gibbons, Hamilton, Ring-Kurtz, & Gallop, 2011). This
evidence has been criticized, however, on the basis that it is
correlational, and thus, the alliance may not be causal to outcomes,
as (a) it may be the patient’s contributions to the alliance that are
important (i.e., patients with better prognoses are able to form
better alliances and have better outcomes), (b) early symptom
change creates the alliance, and (c) the alliance may help patients
feel better (i.e., general well-being) but will not affect symptom-
atology (Baker et al., 2008;DeRubeis et al., 2005;Siev et al.,
2009). Several studies from a CF approach have been conducted to
investigate these hypotheses. Baldwin, Wampold, and Imel (2007)
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used multilevel models to disentangle therapist and patient contri-
butions to the alliance and found that it was the therapists’ con-
tributions to the alliance that predicted outcome rather than the
patients’ contribution. That is, therapists who were able to form
better alliances generally with their patients had better outcomes;
however, patients who were able to form a better alliance with a
given therapist did not have better outcomes than patients with
poorer alliances with the same therapist, a result that has been
replicated in primary studies (Dinger, Strack, Leichsenring,
Wilmers, & Schauenburg, 2008;Zuroff, Kelly, Leybman, Blatt, &
Wampold, 2010) and meta-analytically (Del Re, Flückiger, Hor-
vath, Symonds, & Wampold, 2012). Moreover, there is accumu-
lating evidence that the alliance is predictive of patient change
after controlling for early symptom change (e.g., Baldwin et al.,
2007;Crits-Christoph et al., 2009;Crits-Christoph et al., 2011;
Falkenström, Granström, & Holmqvist, 2013;Webb et al., 2011).
Finally, the alliance is not weaker in ESTs, in disorder-specific
manualized treatments, for symptoms measures, for cognitive or
behavioral treatments, or in RCTs (vs. naturalistic studies) (Flück-
iger, Del Re, Wampold, Symonds, & Horvath, 2012). Nor is it
weaker in family therapy, with one hallmark study (Alexander,
Barton, Schiavo, & Parsons, 1976) of the behavioral treatment of
delinquent adolescents finding that therapists’ relationship skills
accounted for 59% of the outcome variance. That is to say, it
appears that the alliance is an important factor in psychotherapy
outcomes. Therefore, an inclusive EBP approach would not disre-
gard a body of evidence simply because one believes it has “little
promise” for clinical psychology.
How Important Is the Individual Therapist as a
Predictor of Outcome?
According to the most recent review of the therapist effects
literature (Baldwin & Imel, 2013), approximately 5% of outcome
variance is attributable to therapists. Given that the treatment
method accounts for roughly 1% of total outcome variance
(Wampold, 2001; see Table 1 for list of effect sizes for different
psychotherapeutic variables), therapist differences certainly hold
their own as variables of scientific importance and for the im-
provement of the quality of care.
One of the conjectures of the CF approach is that therapists are
important to the success of the treatment (a conjecture with which
many proponents of ESTs also agree) and trials that do not exam-
ine therapist effects are consequently biased in that they overesti-
mate treatment effects (Wampold & Serlin, 2000). Moreover,
using therapists who have an allegiance to other treatments also
biases the outcomes. The CF approach predicts that there will be
variation among therapists in terms of their outcomes, as some
therapists are more skilled, even if they are delivering the same
treatment with adequate adherence. Therapist effects have been
observed in both clinical trials and naturalistic settings for indi-
vidual therapy (see Baldwin & Imel, 2013, for a review), and
family/couple therapy (Alexander et al., 1976;Blow, Sprenkle, &
Davis, 2007), although these results have been challenged (Crits-
Christoph et al., 1991;Elkin, Falconnier, Martinovich, & Ma-
honey, 2006;Siev et al., 2009). The primary criticism is that the
variability among therapists is owing to variability in the manner
in which the treatment is delivered: If therapists give the treatment
as designed (with adequate adherence and competence), then ther-
apist effects would disappear (Shafran et al., 2009). This appears
to be an adherence issue, and yet adherence (as well as rated
competence) appears to not be related to outcome (Webb et al.,
2010; but see Leichsenring et al., 2011). Importantly, we have
begun to identify the actions of more effective therapists and they
appear to be related to aspects of the CF approach. More effective
therapists, as mentioned above, generally form better alliances
with their patients (Baldwin et al., 2007) and have better facilita-
tive interpersonal skills (Anderson, Ogles, Patterson, Lambert, &
Vermeersch, 2009), and provide an emotionally activating rela-
tionship (Laska, Smith, Wislocki, Minami, & Wampold, 2013), as
predicted by the CF perspective.
Are All Components of an EST Necessary?
The EST prediction is that all the ingredients of a treatment are
necessary, as they target specific mechanisms of change, whereas
Table 1
Effect Sizes for Common Factors and Specific Ingredients
Factor Number of
studies Number of
patients Effect size
Cohen’s d% of variability
in outcomes
Common factors
190 2,630 .57 7.5
59 3,599 .63 9.0
Goal consensus/collaboration
15 1,302 .72 11.5
Positive regard/affirmation
18 1,067 .56 7.3
16 863 .49 5.7
46 14,519 .46 5.0
Specific ingredients
Differences between treatments
295 5,900 .20 1.0
Specific ingredients (dismantling)
30 871 .01 0.0
Adherence to protocol
28 1,334 .04 0.1
Rated competence in delivering particular treatment
18 633 .14 0.5
Norcross and Lambert (2011).
Baldwin and Imel, 2013.
Wampold et al. (1997); confirmed by various
other meta-analyses for specific disorders.
Bell et al., 2013 (targeted variables); see also Ahn and Wampold
Webb, DeRubeis, and Barber (2010).
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the CF program states the opposite. We examine this conjecture by
focusing on treatments for depression and PTSD.
According to the cognitive model, “changes in cognitions caus-
ally predict changes in psychopathology” (Hofmann, 2013), al-
though it appears that this treatment may not be effective because
of the cognitive components, as demonstrated by a dismantling
study (Jacobson et al., 1996) and replicated by Dimidjian et al.
(2006) (however, see Hofmann, 2008 for counterargument). The
purpose of the Jacobson study was to “provide an experimental test
of the theory of change put forth by Beck et al. (1979) to explain
the efficacy of cognitive–behavioral therapy (CT) for depression”
(p. 295), and it was hypothesized that “according to the cognitive
theory of depression, CT should work significantly better than AT
[modifying automatic thoughts behavioral activation], which in
turn, should work significantly better than BA [behavioral activa-
tion] only” (p. 296). Contrary to expectations, the outcomes of the
BA condition were comparable with CT at termination and follow-
up, and the authors concluded.
These findings run contrary to hypotheses generated by the cognitive
model of depression put forth by Beck and his associates (1979), who
proposed that direct efforts aimed at modifying negative schema are
necessary to maximize treatment outcome and prevent relapse (p.
Concordantly, as noted by Dimidjian et al. (2006), “This growing
body of research raises questions about the necessity of directly
targeting negative thinking to achieve treatment response” (p.
Regarding PTSD, a number of treatments have been found to be
efficacious and have been classified as ESTs, including PE and
cognitive processing therapy (CPT; Resick & Schnicke, 1992).
However, EMDR has also been shown to be as effective as PE and
CBT (Seidler & Wagner, 2006), a finding that is somewhat prob-
lematic because EMDR has been described as “pseudoscience”
and has been compared with Mesmerism (McNally, 1999). To
accommodate EMDR as an EST, a distinction between treatments
that were “trauma-focused” and those that were not was invoked to
maintain a hierarchy among treatments (Ehlers et al., 2010). Yet,
trauma-focused treatments have not been found to be more effi-
cacious than nontrauma-focused treatments that were intended to
be therapeutic (Wampold et al., 2010). PCT, a treatment developed
as a control for PE and CBT that contains no exposure and no
cognitive components, and is not trauma-focused, became as ef-
fective as other ESTs for PTSD when it was provided by therapists
who were trained to deliver it faithfully (Classen et al., 2011;
McDonagh et al., 2005;Schnurr et al., 2007), and is now classified
by the Society of Clinical Psychology as a research-supported
treatment with “strong research support” (Hajcak & Starr, n.d.;
Frost, Laska, & Wampold, 2014). Moreover, dismantling studies
of ESTs for PTSD reveal that when the purported ingredients of
the treatment are removed, the treatment remains efficacious (Bry-
ant et al., 2008;Resick et al., 2008).
Furthermore, two meta-analyses of dismantling studies have
showed that removing critical specific ingredients did not attenuate
the effects of the treatment. Ahn & Wampold (2001) included 27
studies and found no difference when components were removed
or added. More recently, Bell, Marcus, & Goodlad (2013) con-
ducted a meta-analysis of 66 different dismantling studies and
replicated the results of Ahn and Wampold. Although tentative at
this time, there is insufficient evidence to reject the null hypothesis
of no differences.
We claim there is no construction of science that at this time
should privilege the EST perspective over the CF approach. De-
cisions about whether to abandon a research program are made by
the scientific community and clearly clinical psychology has not
abandoned the EST perspective; indeed, it is the received view at
the present time. However, “the problem fever of science is raised
by the proliferation of rival theories rather than by counterexam-
ples or anomalies” (Lakatos, 1970, p. 121) and consequently the
validity of the EST approach requires that it be examined vis-a
rival theories, the most prominent of which is CF. We believe both
perspectives, which are not mutually exclusive, provide useful
heuristics for testing the mechanisms of change in psychotherapy,
and both are needed if we are to make impact on reducing the
burden of mental illness for consumers of psychotherapy, a topic
to which we now turn.
Implications of the EST and CF Approaches for Policy
In this section, we examine the policy implications for improv-
ing the quality of care from both the EST and CF perspectives. Our
purpose here is to suggest that policy guided by the EST approach
is useful, but that certain limitations have been overlooked.
EST and Quality Improvement
We believe transporting ESTs into practice settings should be
one aspect of EBP. Yet, the prioritization of ESTs as the only
“ethical” EBP requires some reexamination. For example, as noted
by Chambless and Crits-Christoph (2006).
Thus, in the face of evidence that Tx A works, it is not sufficient for
the practitioner who prefers Tx B to rest on the fact that no one has
shown that TxB is ineffective. Tx A remains the ethical choice until
the success of Tx B is documented (emphasis added, p. 193).
However rational this seems, caution must be exercised when
adopting this strategy.
EST implementation involves training (and supervising, as we
shall see) therapists to deliver ESTs in practice settings, in lieu of
the treatments they are currently practicing. The essential premise
is that having therapists deliver an EST, rather than the currently
delivered treatment, will result in better outcomes. This premise
rests on the EST conjecture that some treatments are more effec-
tive than others, which as we have argued, is questionable. How-
ever, there is evidence that the marginal utility of transporting
ESTs may be small. In a large data set of 12,743 patients collected
in a managed care setting, therapists treating depressed patients
obtained outcomes that were comparable with benchmarks set in
clinical trials, and did so in fewer sessions (Minami et al., 2008,
see also Saxon & Barkham, 2012). That is to say, practicing
therapists appear to be achieving, on average, commendable out-
comes, a fact that seems to be generally ignored by many. More-
over, there are few controlled trials in naturalistic settings com-
paring the delivery of ESTs to treatment-as-usual (TAU) in which
the TAU involves comparable doses of psychotherapeutic services.
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Most of the comparisons of EST and TAU involve a TAU that is
not a legitimate psychotherapy service, such as referral to primary
care physician (Wampold et al., 2011;Weisz, Jensen-Doss, &
Hawley, 2006). When ESTs are compared with TAU that involves
comparable doses of therapy, there is insufficient evidence to
conclude that ESTs are superior for depression and anxiety in
either adult or youth clients (Spielmans, Gatlin, & McFall, 2010;
Wampold et al., 2011). In other words, there is insufficient evi-
dence at this point in time to suggest that implementing ESTs will
significantly improve on the quality of mental health services
already in place.
When differences are found in effectiveness trials, the positive
benefits may have little to do with the specific treatments being
transported, and more to do with changing unproductive aspects of
systems of care (e.g., identifying and removing iatrogenic treat-
ments, providing less competent therapists with a theoretical ra-
tionale, extra training and supervision for therapists in the exper-
imental condition, etc.). For example, in an effectiveness trial of
CBT for depression (Simons et al., 2010), therapists in the TAU
condition received no workshop, no extra training, and no super-
vision or consultation, whereas therapists in the CBT condition
received a 2-Day 12-hr workshop, and 16 1-hr group telephone
consultations for 1 year. Furthermore, claims that ESTs improve
care beyond TAU simply because a significant prepost effect was
found for the EST are spurious absent any preintervention outcome
A second issue is related to therapists. Some have argued that
therapist effects can be eliminated through proper training and
adequate adherence (Crits-Christoph et al., 1991), yet RCTs of
ESTs do not use a random sample of therapists. Rather, therapists
in clinical trials typically are selected for their expertise and are
removed from the study if they cannot deliver treatment skillfully
(see Suris et al., 2013). The assumption is that transporting ESTs
to practice settings will be uniformly effective if therapists deliver
the protocol with adequate fidelity. Yet, growing evidence sug-
gests otherwise. There is evidence that therapist variability is
significant even in practice settings in which therapists receive
extensive training and supervision in an EST by a nationally
recognized trainer (Laska et al., 2013).
Unfortunately, the assumption of therapist uniformity has per-
sisted for decades. As noted by Donald Kiesler (1966) almost 50
years ago.
Despite this token admission of therapist differences, the Uniformity
Assumption still abounds in much psychotherapy research. Patients
are still assigned to “psychotherapy” as if it were a uniform homo-
geneous treatment, and to psychotherapy with different therapists as if
therapist differences were irrelevant...Ifpsychotherapy research is
to advance, it must first begin to identify and measure these therapist
variables so relevant to eventual outcome (personality characteristics,
technique factors, relationship variables, role expectancies, and the
like) (pp. 112–113).
Although the methodological rigor of psychotherapy research has
come a long way over the last several decades, we may have lost
our way in asking some of the most important questions. Perhaps
there is no more compelling and relevant area for advancing the
study of which therapist variables to “identify and measure,” than
the study of what expert therapists, of any theoretical persuasion,
actually do, as urged over 40 years ago by Bergin and Strupp
Cost under the EST approach, treatments are designed to be
disorder-specific. In naturalistic settings, clients typically present
with a wide range of comorbid conditions and therapists treat
patients with a variety of disorders. Thus, to meet the needs of
individuals under the current model, providers would need to be
trained in multiple ESTs for various disorders (e.g., ACT for
Depression, PE for PTSD, CBT for panic disorder). This concern
is highlighted by McHugh and Barlow (2010):
For example, even at specialty outpatient clinical service settings,
clinicians would need to receive training in multiple individual pro-
tocols to be able to treat the target patient population using ESTs. A
community mental health center that serves a wider variety of clinical
presentations would require training in even more protocols. Attempt-
ing to maintain fidelity to each of these individual treatments would
present an enormous challenge to a clinical care system. Given the
cost of didactic (e.g., workshop, written materials) and competence
(e.g., supervision and feedback) training, implementing multiple treat-
ments to a facility is often not a feasible consideration (p. 951).
The costs are indeed great. Suppose a therapist in practice, who
has not been trained in an EST, heeds the advice of Chambless and
Crits-Christoph (2006) as stated above. Because this therapist sees
many depressed patients, she decides to be trained in CBT for
depression, the gold standard of treatments for depression. The
cost of participating in a 3-day CBT Level I workshop for depres-
sion offered by the Beck Institute for Cognitive Therapy is $1,200
which one must add travel costs (airfare, hotel, and meals, say
conservatively another $1,200 for someone who does not live near
Philadelphia) and opportunity costs (i.e., lost income for at least 3
days, say at $100/hr, or conservatively $1,800), for a total of
$4,200. In addition, once therapists have completed the workshop,
ongoing supervision (competence training) is required at an addi-
tional cost to the individual therapist. Moreover, dissemination
experts claim that there will be “drift” in adherence to treatment
protocols, and so the practitioner would need to have refresher
courses to adequately provide the treatment (Waller, 2009). Keep-
ing in mind that the practitioner would need to learn several, and
perhaps many, ESTs to deliver such treatments to most of his or
her patients, the time and cost will be great. There might be some
cost savings for scale, say for a clinic that might contract for group
training. For a system of care, however, the cost could be great—
the Department of Veterans Affairs spent over $20 million dollars
to roll out ESTs between 2007 and 2010 (Ruzek, Karlin, & Zeiss,
2012). These costs must be considered in comparison to the actual
benefit to an individual practitioner, clinic, or system of care, all of
which are largely unknown.
Unfortunately, the costs are not limited to practitioners, clinics,
and systems of care. Because the EST approach is the received
view by many clinical scientists, we were interested in knowing
how much is spent comparing two treatments intended to be
therapeutic and what the marginal utility of such research is, in
terms of knowledge. That is, what have we learned, and at what
cost? We conducted a systematic search of several journals and
relevant meta-analyses to find published comparative clinical trials
that were funded by the NIMH between the years 1992 and 2009
for the treatment of anxiety and depression (Laska, 2012). We
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found eight such studies, which included 483 patients and nine
direct comparisons (see Figure 1), with a total cost of $11,760,874.
A meta-analysis revealed that the null hypothesis that the true
effects were zero could not be rejected, using the methods devel-
oped by Wampold and Serlin (2014). The only study with an effect
statistically different from zero was Markowitz et al. (1998), which
found IPT to be superior to CBT for depressed HIV patients. That
is to say, for over $11 million, one null hypothesis was rejected,
the overall effect was zero, and the actionable evidence is ques-
tionable: Should practitioners treating HIV depressed patients with
CBT be retrained to provide IPT?
The dollar costs of disseminating multiple ESTs for multiple
disorders to individual clinicians and health care systems are
certainly prohibitive and make such efforts challenging. Yet, there
lurks another aspect of the practicability of such aims that is rarely
acknowledged. Although the feasibility of providing a clinical
intervention usually emphasizes patient acceptability (e.g., APA
Presidential Task Force on Evidence-Based Practice, 2006), both
the interventions themselves and their supporting empirical base
must be acceptable to practitioners. Just as different treatment
approaches may “fit” the person of the therapist better than others,
even the most compelling treatment research, whether based in the
EST or CF tradition, will have little impact on clinical practice if
it does not match the “fit” between the therapist’s preferred
method of therapy and her Self (Gurman, 2011). There is substan-
tial evidence (e.g., Orlinsky, Botermanns & Ronnestad, 2001) that
psychotherapy research, including RCT-focused research (Stewart,
Stirman, & Chambless, 2012) generally has limited influence on
how therapists practice. Rather than viewing the gap between
RCTs and practice as “resistance” by clinicians, as some (Lilien-
feld et al., 2013) have described the situation, we and our clients
may be better served by acknowledging that, as shown here, there
are many empirically legitimate ways to both practice and inves-
tigate psychotherapy. Skynner’s (1980) quip that we need “differ-
ent thinks for different shrinks” (p. 274) is consistent with the CF
approach discussed here.
CF and Quality Improvement
The premises of quality improvement from the CF perspective
are consistent with “practice-based evidence” (Barkham, Hardy, &
Mellor-Clark, 2010;Duncan, Miller, Wampold, & Hubble, 2010),
also aptly referred to as “progress research” (Pinsof & Wynne,
2000). In this approach, patient progress is assessed regularly, and
these data are used to improve the quality of care. That is to say,
the evidence is derived from actual practice, mirroring best prac-
tices in quality improvement in other fields. Our purpose here is
not to suggest specific competency standards for therapists or to
offer technical protocols for the administration of quality improve-
ment systems. Rather, it is to advance the argument that the CF
approach provides a scientifically grounded foundation for
practice-based quality improvement that should complement RCT-
based approaches to enhancing clinical care. Thus, for example,
the possibility that a clinical focus on the five central components
of the CF approach described earlier might improve outcomes
deserves further investigation, even as technical refinements of
RCT-based methods continue.
Feedback. Feedback systems typically consist of one or more
self-report measures completed by clients regularly, and these data
are then used in real time to provide individually tailored treatment
decisions. By way of analogy, feedback systems have been de-
scribed as a “mental health vital signs lab test” (Lambert, 2013b).
Both “rationally derived methods,” which set predetermined cri-
teria for clinically significant improvement, and “empirically de-
rived methods,” which compare expected versus actual rates of
change (see Castonguay, Barkham, Lutz, & McAleavey, 2013),
have been adopted in systems of care.
One area in which feedback systems have the potential to make
a significant impact is in regards to the “Lake Wabegon” effect.
Studies have shown that therapists, regardless of approach, are
poor at self-assessment and too often have a biased picture of
treatment progress. For example, in one study, roughly 90% of
therapists rated themselves in the top 25% of outcomes (Walfish,
McAlister, O’Donnell, & Lambert, 2012). Feedback systems pro-
tect against this self-assessment bias and introduce data-driven
methods into the therapy process. Simply providing therapists with
feedback about the progress of their patients has shown to prevent
treatment failures and improve outcomes (Lambert & Shimokawa,
2011;Shimokawa, Lambert, & Smart, 2010). Moreover, providing
feedback reduces treatment length for patients making expected
progress, but also keeps patients at risk for failure in therapy from
dropping out. In one example where the Partners for Change
Outcome Management System (PCOMS) was implemented by the
Center for Family Services (CFS) in Palm Beach, Flordia, Bohan-
ske and Franczak (2010) note:
For example, average length of stay decreased more than 40%. Can-
cellation and no-show rates dropped by 40% and 25%, respectively.
Most impressive of all, the percentage of clients in long term treat-
ment that experienced little to no measured improvement fell by 80%!
In 1 year, CFS saved nearly $500,000, funds that were used to hire
additional staff and provide more services (p. 308).
Indeed, the Substance Abuse and Mental Health Services Ad-
ministration (SAMHSA) National Registry of Evidence-based
Programs and Practices (NREPP) only includes programs and
practices that meet strict standards (see http://www.nrepp.samhsa
.gov/). Lambert’s OQ Analyst, Miller’s (PCOMS), and Norcross’
Evidence-Based Therapy Relationships are included in NREPP,
indicating that aspects of the CF model can be translated into
viable evidence-based programs and practices.
Alliance. Real-time feedback systems that include attention to
CF factors may have great potential to address the central matter of
how change happens in therapy by considering a wider range of
Figure 1. Forest plot of effects of NIMH-funded comparative trials.
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potential mediators of change than is typically attended to in
RCT-based models. The use of practice-based evidence is pro-
gressing importantly toward giving therapists information about
various elements in the CF approach, particularly the alliance.
Lambert (2009) has developed clinical support tools that assess
alliance, readiness for change, and social support. Miller and
colleagues (Duncan, 2012) have developed the Session Rating
Scale to assess the quality of the session and the alliance, so that
therapist can monitor not only the outcomes of therapy but also the
progress of therapy. Pinsof et al. (2009) developed an inventory to
assess treatment progress and the therapeutic alliance focused on
varying therapy systems, that is, couples and families as well as
individuals. Given that a strong therapeutic alliance is one of the
most robust predictors of outcome, continued data-driven efforts in
this area has the potential to greatly improve care.
Therapists. Examination of therapist effects in practice set-
tings indicate that most therapists achieve desirable outcomes,
which is to say that they meet the benchmarks for various disorders
(Minami et al., 2008;Minami, Wampold, Serlin, Kircher, &
Brown, 2007;Wampold & Brown, 2005). What is most important
from the CF perspective is investigating those therapists who
achieve expected outcomes to identify what it is they are doing.
Given that most RCTs typically include less than 12 therapists,
rendering examination of therapist effects difficult, quality im-
provement efforts from a CF perspective should focus on those
therapist behaviors in naturalistic settings that contribute to ex-
pected outcomes. Why is it that therapist differences have been
acknowledged for over 40 years, yet as a field we are not much
further in understanding the role of therapist variables than when
Kiesler first acknowledged the “uniformity assumption” almost
half a century ago? If we continue to disregard the importance of
the therapist, a full one half of the clinical dyad, we drastically
limit our ability to reduce the burden of mental illness. In order for
EBP to achieve the aim of reducing mental illness, greater empha-
sis must be placed on the therapist, regardless of theoretical ori-
entation or system of care in which he or she is examined.
Additionally, in naturalistic data sets it is clear that the patients
of some therapists consistently fail to make expected progress
(Minami et al., 2008;Saxon & Barkham, 2012;Wampold &
Brown, 2005). The quality of service would be dramatically im-
proved by assisting these therapists to achieve better outcomes.
Managers of care could identify these therapists and provide
additional training or supervision. However, the training provided
should be designed to address particular skill deficits. From our
perspective, the training and supervision might well involve a
focus on relationship skills, if it is determined that those are
lacking. However, in our experience some therapists fail to deliver
a clear, cogent, and consistent treatment, which is one of the
important aspects of the CF approach (Wampold & Budge, 2012).
From the CF perspective, the particular treatment is not inherently
crucial for most disorders, and adherence to the protocol is not
crucial, but providing a cogent and acceptable explanation for the
patient’s difficulties and engaging the patient in healthy actions
through a treatment structure is crucial. Thus, training in an EST
may indeed be helpful, if there is evidence that a particular
therapist is not achieving desirable outcomes because he or she is
not providing an adequate treatment structure. If all attempts to
assist a therapist to meet some consensual minimal outcome stan-
dards fail, then the profession, as well as the manager of care,
needs to determine whether in the best interest of patients, the
therapist should be “counseled” to find another line of work. This
would be a controversial action but one that is accord with pro-
fessional standards and accountability. By way of offering some
context for this recommendation, we note that Saxon and Barkham
(2012) found that of 119 therapists in practice, 19 had outcomes
considered “below average” and if their 1,947 patients had been
seen by “average” therapists an additional 265 patients would have
recovered (see also Baldwin & Imel, 2013).
Training. The ideal training program, in our view, should
contain elements of the both the EST and the CF perspectives.
Psychotherapy trainees should be trained to provide ESTs as well
as be trained in feedback systems, and how to form and repair
strong working alliances, express empathy, and collaborate on
treatment goals. We recommend going one step further, however,
to provide “competency-based” certification. That is, to be certi-
fied, trainees would need to attain outcomes with various types of
patients that meet a given standard (e.g., the benchmark for a
particular disorder or type of patient). Such a competency-based
system would help to attenuate the schism between Baker et al.’s
(2008) proposed Psychological Clinical Science Accreditation
System (PCSAS) and the American Psychological Association
(APA) accreditation. Standards of accountability would dictate
that students graduating from PCSAS or APA-accredited programs
should have demonstrated that they are competent therapists by
achieving commendable outcomes, regardless of the emphasis of
their training programs and regardless of treatment approach.
Such a balanced approach to clinical training, open to scientific
input from both the CF and EST points of view, would be in full
accord with both the standards for EBP set forth by the APA
(2006) and the important recently emerging emphasis on transdi-
agnostic understanding of emotional and behavioral problems
(Barlow et al., 2011) and related unifying principles of psycho-
therapeutic change.
Conclusions—and a Challenge
Increasingly, psychotherapy theory and research of late has
focused on how the CF and the specific ingredients work together
to produce the benefits of therapy (Hoffart, Borge, Sexton, Clark,
& Wampold, 2012;Owen & Hilsenroth, 2011;Pesale, Hilsenroth,
& Owen, 2012;Ulvenes et al., 2012;Wampold & Budge, 2012).
Much of this research shows that the CF do their work differently
in different therapies—but clearly, both the CF and the specific
ingredients need to be integrated.
We have presented the science of two research perspectives and
suggested some ways to improve the quality of psychotherapeutic
care, including the use of feedback systems as a unifying means of
establishing accountability for treatment outcomes. In many quar-
ters, the EST approach is the received view. We have attempted to
make the case for an alternative and complementary CF approach,
which has significant consequences for improving mental health
services. Rather than argue about which perspective is more or less
scientific, we issue the following challenge: How can we integrate
the two models of empirical inquiry in a way that the field can
move forward?
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Received July 2, 2013
Accepted July 5, 2013
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... Sin embargo, no se ha conseguido demostrar la supremacía de unas frente a otras; aunque ocasionalmente aparece algún artículo en el que se señalan resultados significativos en un modelo particular, un análisis crítico de los datos revela que no hay apenas diferencias en la efectividad de los tratamientos utilizados (Duncan, 2002). En efecto, numerosas investigaciones y varios metaanálisis concluyen que diferentes enfoques de intervención sociorelacional producen efectos similares (Chwalisz, 2001;De Felice et al., 2019;Lambert y Bergin, 1994;Lambert y Kleinstäuber, 2016;Laska, Gurman y Wampold, 2014;Norcross y Wampold, 2011;Wampold et al., 1997;Wampold, 2001Wampold, , 2015, por lo que se comienza a investigar sobre factores que van más allá del enfoque utilizado. ...
... Según afirman Laska et al. (2014), cualquier enfoque que incluya todos los ingredientes del enfoque de los factores comunes, resultará eficaz. Estos ingredientes esenciales son (Laska et al., 2014): a) vínculo emocional entre profesional y cliente; b) un entorno seguro en el que llevar a cabo el proceso; c) un profesional que proporciona explicación ajustada al cliente (a nivel cultural) para su malestar emocional; d) una explicación que resulte adaptativa y que sea aceptada por el cliente; y e) un conjunto de procedimientos en los que el cliente se compromete e involucra, que lleva a que el cliente pueda desarrollar elementos que resulten positivos, útiles o adaptativos. ...
... Según afirman Laska et al. (2014), cualquier enfoque que incluya todos los ingredientes del enfoque de los factores comunes, resultará eficaz. Estos ingredientes esenciales son (Laska et al., 2014): a) vínculo emocional entre profesional y cliente; b) un entorno seguro en el que llevar a cabo el proceso; c) un profesional que proporciona explicación ajustada al cliente (a nivel cultural) para su malestar emocional; d) una explicación que resulte adaptativa y que sea aceptada por el cliente; y e) un conjunto de procedimientos en los que el cliente se compromete e involucra, que lleva a que el cliente pueda desarrollar elementos que resulten positivos, útiles o adaptativos. Por su parte, Lambert y Oggles (2014) consideran que el término "factores comunes" incluye prácticas que van más allá de la relación profesional-cliente, como por ejemplo la percepción del cliente acerca de la experticidad del profesional. ...
... Participants were also less likely to report stigma-related concerns compared to those who had not received a wellness check. Consistent with theory on the common factors in counseling and the contextual model of psychotherapy (Laska et al., 2014), feeling listened to and learning new skills partially mediated the association between perceived wellness check usefulness and study outcomes, although acquiring a new perspective about problems did not. While not a randomized trial, this evaluation suggests that wellness checks are associated with programmatic goals: improved attitudes toward care seeking, resilience, and thriving. ...
... Thus, we also examined what characteristics of the wellness check mediated the relationship between perceiving the wellness check as useful and study outcomes. To examine this question, we turned to research on common factors in psychotherapy (Laska et al., 2014). ...
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As part of an Army pilot program, mandatory annual wellness checks were initiated to introduce individuals to counseling and to support psychological resilience and thriving. The program was evaluated using a cross-sectional survey completed by 7,831 soldiers. Findings revealed that about half of soldiers who reported a wellness check rated the check at least moderately helpful in their professional and personal lives. Participants receiving a wellness check reported being more likely to report willingness to seek help if they were to have mental health problems and to report higher levels of resilience and thriving even after controlling for rank, age, education, months in the unit, and trait negative affect. Participants were also less likely to report stigma-related concerns compared to those who had not received a wellness check. Consistent with theory on the common factors in counseling and the contextual model of psychotherapy (Laska et al., 2014), feeling listened to and learning new skills partially mediated the association between perceived wellness check usefulness and study outcomes, although acquiring a new perspective about problems did not. While not a randomized trial, this evaluation suggests that wellness checks are associated with programmatic goals: improved attitudes toward care seeking, resilience, and thriving. Future work should consider ways to ensure counselors address therapeutic common factors and should use a randomized, longitudinal design. Study findings have implications for implementing programs like wellness checks for military personnel and others working in high-stress occupations like first responders. (PsycInfo Database Record (c) 2023 APA, all rights reserved).
... On the other hand, a large and growing body of research has substantiated the impact of the relationship on the treatment (Norcross & Lambert, 2018;Geller & Porges, 2014). A meta-analysis of what contributes to treatment outcome (Laska, et al., 2014) found that method or model came in well behind such common factors as goal consensus, empathy, the therapeutic alliance, positive regard, and genuineness. ...
... Her openness, curiosity and willingness to incorporate new methods and models while exploring ways in which they were or were not a pattern match to her previous CBT training is an example of the kind of thinking that will move the field forward, toward greater flexibility and adaptability. Her work here is an example of both the assimilative integration (Messer, 2019) and the common factors (Laska, et al., 2014;Frank, 1973) approaches to psychotherapy integration. She incorporated the newer elements of AEDP into her existing behavioral framework, her home base, to the great benefit of the client. ...
Exposure is hypothesized to be a key active ingredient in several approaches to psychotherapy. Dr. Irada Yunusova (2023) explores this as a common element in both Accelerated Experiential Dynamic Psychotherapy (AEDP) and behavioral exposure therapy. The current commentary elaborates on other important factors that contribute to maximizing the effectiveness of interventions in both these models. These include titrating the level of challenge, memory consolidation, common factors, and neuroplasticity. Dr. Yunusova’s detailed case review is an example of assimilative integration, where one can see her incorporation of a model new to her (AEDP) into her home base of Behavior Therapy, as well as the factors noted above that enhance its effectiveness.
... It may be that although some patients cannot use certain change mechanisms during treatment, such as insight, patients may improve if their therapists engage them in treatment with a positive therapeutic alliance and emphasize other change mechanisms (Balabanovic & Hayton, 2019). Because there are many alternative mechanisms, even if some of them are rejected, the outcome is a result of the interplay between multiple mechanisms (Laska, Gurman, & Wampold, 2013). ...
... Este processo constrói-se no seio de uma relação empática, securizante e de confidencialidade entre psicólogo e paciente e em que, numa aliança de trabalho, o profissional procura com-preender e contextualizar as dificuldades do paciente, devolvendo-lhe conteúdos que possam aumentar o seu potencial adaptativo e apoiá-lo num conjunto de mudanças e/ou resoluções percebidas como positivas. 22 Importa ainda salientar o contributo da abordagem psicológica para a humanização dos cuidados de saúde nos vários contextos hospitalares e, em particular, a redução do estigma associado às doenças mentais e à vulnerabilidade psicológica, sempre no sentido da melhoria da adesão aos planos terapêuticos e do enfoque na funcionalidade do indivíduo. ...
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Psychology is recognized as an autonomous technical-scientific area, evidence-based, particularly involved in the promotion of global health, prevention and treatment of psychological disorders, aiming to increase health gains. Its integration into the different levels of care has been progressive, meeting standards of quality, effectiveness, equity, guaranteeing the safety of citizens and respect for human rights. Hospitals constitute one of the most important health care environments where clinical and health psychology has expanded as a specific career. This article reviews the historical path of Psychology integration in hospital care, its identity construction, and the specificity of its actions in several clinical domains, supporting a close articulation with medical and non-medical specialties and various fields of scientific knowledge. Some of the main future challenges in this area of knowledge are discussed, with a view of maximizing mental health protective factors and mitigating vulnerabilities in specific groups.
... Ainsi, Markus et al. (2014), qui reviennent sur la célèbre hypothèse du Dodo, re-testée par Wampold en 1997, où il concluait à l'efficacité similaire des différentes approches thérapeutiques, affirme que la TCC serait supérieure dans les conséquences à court terme en post traitement mais que les différences ne sont que minimes à long terme. De même Laska, Gurman, et Wampold (2013) indiquent que puisque les traitements empiriquement validés (EST), ont pris racines dans les études randomisées et contrôlées (RCT) et sont le point de vue généralement admis, alors ils proposent d'inclure la perspective des facteurs communs (CF) comme une perspective additionnelle elle aussi empiriquement validée, afin de contribuer au mieux-être des patients et plaident en faveur d'une intégration de ces deux perspectives. Hoffman & Barlow (2014) dans un article au titre éloquent (Evidence-Based psychological interventions and the common factor approches : the beginnings of a rapprochement ?) montrent que chacun semble avoir mis « de l'eau dans son vin ». ...
Vouloir évaluer les psychothérapies, c’est avant tout comprendre le chemin parcouru et notamment la controverse entre deux modèles : celui dit médical et celui dit contextuel. Après avoir mis en exergue l’évolution en marche et nécessaire vers les approches processuelles en matière de psychopathologie et de psychothérapie, nous poserons la question de savoir si une synthèse - presque une entente - pourrait être envisagée de ces deux courants bien souvent opposés. Nous développerons l’exemple des évolutions récentes en thérapies comportementales et cognitives (TCC) et interrogerons ensuite la situation particulière en France, telle qu’elle nous apparaît, entre approches psychanalytiques et TCC et ses enjeux concernant les recherches sur l’évaluation des psychothérapies.
This chapter commences with a brief description of the complexities conceptualising goals in psychodynamic psychotherapy as they differ across different schools. In addition, some goals are inferred rather than being explicit. Nonetheless, the author goes on to delineate goals which are relevant to early, middle, and end stages of a course of psychodynamic therapy. These include promotion of a positive alliance, a description of ‘common factors’ in therapy, and also some relevant technical goals. Final stage goals consist of management of the ending and enabling the ability to mourn the lost good object of the therapist. An alternative framework to conceptualising goals is presented in terms of symptom relief, life adjustment, personality change, and use of relevant procedures as being necessary. Clinical vignettes are used to illustrate these concepts. Finally, there is a brief section on current contributions from neuroscience specifically related to psychodynamic psychotherapy.
Purpose Effective counseling skills are included in standards of practice by speech-language pathology accrediting and training programs, although many speech-language pathologists (SLPs) continue to report a lack of skills in this area. The purpose of this study was to determine whether SLP graduate students and early career SLPs who have taken a dedicated counseling course report higher levels of confidence in counseling skills than those whose counseling training was infused across the curriculum. A secondary aim was to determine which specific counseling skills have the strongest relationship with completing a counseling course. Method A survey, adapted from the Counselor Activity Self-Efficacy Scales for Speech-Language Pathologists, was used to gather information from SLP graduate students and early career SLPs using nonprobability sampling. Data were analyzed from 140 surveys. Research questions were answered descriptively and with independent-samples t tests. Correlation analysis was used to determine which counseling skills were linked with completion of a dedicated counseling course. Results Participants who completed a counseling course reported significantly increased confidence across all counseling domains assessed: Helping Skills Exploration, Helping Skills Action, Helping Skills Insight, Emotional Support Skills, and Session Management. Twenty-six counseling skills were significantly correlated to completing a counseling course. Regardless of educational approach, confidence in personal adjustment counseling skills was lower than that in informational counseling skills. However, personal adjustment counseling skills confidence was significantly higher for participants who had completed a dedicated course. Conclusions Overall, the findings of this study suggest that dedicating a course to the education and training of counseling skills in graduate programs may be beneficial. Implications of these findings for clinical applications and future directions in training are discussed.
Questions about when to limit unhelpful treatments are often raised in general medicine but are less commonly considered in psychiatry. Here we describe a survey of U.S. psychiatrists intended to characterize their attitudes about the management of suicidal ideation in patients with severely treatment-refractory illness. Respondents (n = 212) received one of two cases describing a patient with suicidal ideation due to either borderline personality disorder or major depressive disorder. Both patients were described as receiving all guideline-based and plausible emerging treatments. Respondents rated the expected helpfulness and likelihood of recommending each of four types of intervention: hospitalization, additional medication changes, additional neurostimulation, and additional psychotherapy. Across both cases, most respondents said they were likely to provide each intervention, except for additional neurostimulation in borderline personality disorder, while fewer thought each intervention would be helpful. Substantial minorities of respondents indicated that they would provide an intervention they did not think was likely to be helpful. Our results suggest that while most psychiatrists recognize the possibility that some patients are unlikely to be helped by available treatments, many would continue to offer such treatments.
This therapist guide of prolonged exposure (PE) treatment is accompanied by the patient workbook, Reclaiming Your Life from a Traumatic Experience. The treatment and manuals are designed for use by a therapist who is familiar with cognitive behavioral therapy (CBT) and who has undergone an intensive training workshop for prolonged exposure by experts in this therapy. The therapist guide instructs therapists to implement this brief CBT program that targets individuals who are diagnosed with posttraumatic stress disorder (PTSD) or who manifest PTSD symptoms that cause distress and/or dysfunction following various types of trauma. The overall aim of the treatment is to help trauma survivors emotionally process their traumatic experiences to diminish or eliminate PTSD and other trauma-related symptoms. The term prolonged exposure (PE) reflects the fact that the treatment program emerged from the long tradition of exposure therapy for anxiety disorders in which patients are helped to confront safe but anxiety-evoking situations to overcome their unrealistic, excessive fear and anxiety. At the same time, PE has emerged from the adaption and extension of Emotional Processing Theory (EPT) to PTSD, which emphasizes the central role of successfully processing the traumatic memory in the amelioration of PTSD symptoms. Throughout this guide, the authors highlight that emotional processing is the mechanism underlying successful reduction of PTSD symptoms.
Since the original publication of this seminal work, acceptance and commitment therapy (ACT) has come into its own as a widely practiced approach to helping people change. This book provides the definitive statement of ACT—from conceptual and empirical foundations to clinical techniques—written by its originators. ACT is based on the idea that psychological rigidity is a root cause of a wide range of clinical problems. The authors describe effective, innovative ways to cultivate psychological flexibility by detecting and targeting six key processes: defusion, acceptance, attention to the present moment, self-awareness, values, and committed action. Sample therapeutic exercises and patient–therapist dialogues are integrated throughout. New to This Edition *Reflects tremendous advances in ACT clinical applications, theory building, and research. *Psychological flexibility is now the central organizing focus. *Expanded coverage of mindfulness, the therapeutic relationship, relational learning, and case formulation. *Restructured to be more clinician friendly and accessible; focuses on the moment-by-moment process of therapy.
Recent reanalyses suggest that pharmacotherapy was superior to cognitive-behavior therapy in the acute treatment of more severely depressed outpatients in the National Institute of Mental Health Treatment of Depression Collaborative Research Program (TDCRP). At the same time, this finding was neither robust across sites within the TDCRP nor consistent with findings from other studies. D. F. Klein has argued that those other studies were inherently flawed because they did not include pill-placebo controls, an argument that he extended to drug-psychotherapy comparisons in the treatment of panic as well. It is agreed that the inclusion of such controls would have facilitated the interpretation of the findings, but it is not agreed that their omission rendered those studies uninterpretable. Cognitive-behavior therapy remains a viable alternative to pharmacotherapy in the treatment of depression and a particularly promising intervention in the treatment of panic disorder.
Although the consequences of ignoring a nested factor on decisions to reject the null hypothesis of no treatment effects have been discussed in the literature, typically researchers in applied psychology and education ignore treatment providers (often a nested factor) when comparing the efficacy of treatments. The incorrect analysis, however, not only invalidates tests of hypotheses, but it also overestimates the treatment effect. Formulas were derived and a Monte Carlo study was conducted to estimate the degree to which the F statistic and treatment effect size measures are inflated by ignoring the effects due to providers of treatments. These untoward effects are illustrated with examples From psychotherapeutic treatments.