Common factors affecting psychotherapy outcomes: some implications for teaching psychotherapy

Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.

Review Article

Common Factors Affecting Psychotherapy Outcomes:Some Implications for Teaching Psychotherapy

The number of psychotherapies classified as“empirically supported treatments” hasincreased significantly. As the number andscope of empirically supported treatmentsmultiply, it has become impossible to traintherapists in all of these specific modalities.Although the current Accreditation Councilfor Graduate Medical Education requirementsfor psychiatric residents follow an approachbased on specific schools of psychotherapy(emphasizing competency in cognitive-behav-ioral therapy, psychodynamic therapy, andsupportive treatments), evidence suggeststhat we are failing even in these efforts. Indeveloping a specialized PsychotherapyScholars Track in the residency program atthe University of Colorado School of Medicine,we opted to focus initially on teaching thecommon factors in psychotherapy that pos-itively affect psychotherapy outcomes. Thisarticle reviews 6 such broad common factors.(Journal of Psychiatric Practice 2015;21;180–189)

KEY WORDS: common factors, integrative psycho-therapy, psychiatric residency education, psycho-therapy outcomes

In Alice in Wonderland, the Dodo bird famouslydeclaimed, “Everybody has won, and all must haveprizes!” The same phrase, the so-called “Dodo BirdVerdict,” has been applied to controversies sur-rounding the comparative effectiveness of all psy-chotherapies. The “Dodo bird verdict,” which iscontested, does not mean that all of the over 400forms1 of psychotherapy are equally effective. Anexcellent review of many meta-analyses2 conductedin the past 5 to 7 years summarizes the relativesuperiority of various “empirically supported treat-ments (ESTs)” for specific conditions or problems.As codified by the Society of Clinical Psychology(Division 12 of the American Psychological Associ-ation), the standards for designating a psychother-apy as evidence-based require that a psychotherapy

“has been defined in manuals and found efficaciousin at least 2 controlled clinical trials with randomassignment, that include a control condition ofpsychotherapy, placebo, pill, or other treatment andsamples of sufficient power with well-characterizedpatients.”3 Although these standards and the ESTliterature are significant, from a psychotherapytraining perspective, the list of therapies meetingthis gold-standard has grown so rapidly thatattempting to teach the numerous forms of ESTs isnow impractical, if not impossible. Interestedreaders may wish to peruse http://www.apa.org/about/policy/resolution-psychotherapy.aspx for anup-to-date list of psychotherapies considered by thisgroup, their assessments of the degree of supportingevidence, and the extent of controversy associatedwith each therapy.

Current attempts to teach even 3 different formsof psychotherapy as currently required by theAccreditation Council of Graduate Medical Educa-tion (ACGME)—cognitive-behavioral therapy, psy-chodynamic psychotherapy, and supportive psy-chotherapy—have been disappointing. A survey ofpsychiatric residencies in the United States4 indi-cated that residents graduate from training“knowing” much about 1 and sometimes 2 forms ofthe required psychotherapies. This means that, atbest, residents graduate with competence in 1 formof psychotherapy and know a little about one otherschool of psychotherapy.

As teachers of psychotherapy what are we to do?Should we apply the “Dodo Bird Verdict” to trainingin empirically supported psychotherapies? Shouldwe be expected to teach the 10 to 20 forms of

ROBERT FEINSTEIN, MDNOA HEIMAN, PhDJOEL YAGER, MD

FEINSTEIN, HEIMAN, and YAGER: Department of Psy-chiatry, School of Medicine, University of Colorado, Aurora,CO.

Copyright © 2015 Wolters Kluwer Health, Inc. All rightsreserved.

The authors declare no conflicts of interest.

Please send correspondence to: Noa Heiman, PhD, Depart-ment of Psychiatry, University of Colorado, 13001 E. 17thPlace, MS F546, Aurora, CO 80045 (e-mail: [email protected]).

DOI: 10.1097/PRA.0000000000000064

180 May 2015 Journal of Psychiatric Practice Vol. 21, No. 3

http://www.apa.org/about/policy/resolution-psychotherapy

http://www.apa.org/about/policy/resolution-psychotherapy

mailto:[email protected]

mailto:[email protected]


designated psychotherapies when psychiatric resi-dents are not yet widely successful at achievingcompetence in the minimum of 3 forms of psycho-therapy required by the ACGME?

To contend with these challenges, 1 popularstrategy adopted by many training programs hasbeen to teach easier to learn school-based psycho-therapies first. This approach emphasizes basicschool-specific psychotherapy concepts and skills,and then adds teaching and supervision for morecomplex forms of psychotherapy during advancingstages of training. The McMaster PsychotherapyProgram5 has used this strategy. Their systembegins by teaching emotion-focused psychotherapyearly in training because it is foundational,emphasizing listening, empathy, and under-standing emotions as basic skills required forpracticing other forms of psychotherapy. This pro-gram progresses in its teaching to cognitive-behav-ioral therapy, to psychodynamic psychotherapy,and on to other more specialized forms of treatment.

An alternative strategy for teaching psychother-apy is to focus on the common factors that positivelyaffect psychotherapy outcomes. By distilling andsummarizing the common features of many schoolsof psychotherapy, this perspective can generate itsown core principles regarding psychotherapy edu-cation, training, and practice. These principles canbe translated into specific instructional and clinicalpractice goals and objectives; these principles haveinformed our curriculum and are described else-where.6 Learning multiple psychotherapies simul-taneously often leads the novice resident to feelconfused and overwhelmed.7 The common factorsapproach offers the potential advantage ofdecreasing such confusion and can facilitate resi-dent acquisition of foundational therapeutic skills.

In addition, and of great practical importance, thecommon factors approach relieves programs of theburden of finding “good” patients to match theparticular form of treatment the residents are try-ing to learn. In this approach, all patients are “good”patients for learning something about psychother-apy. The common factors approach encouragesclinicians to focus on specific patients and problemsat specific points in time, utilizing specific inter-ventions and tactics from various schools. It placesinterventions at center stage in psychotherapytraining and practice rather than emphasizingtheories or schools of psychotherapy. Thus, only

after common foundational concepts and skills areacquired during the first 2 years of residency doesour Psychotherapy Scholars Track at the Universityof Colorado Medical School also address specificschools of psychotherapy.

The literature reviewed below has helped usdevelop the core principles that serve as our foun-dation for teaching psychotherapy.

SIX COMMON FACTORS AFFECTINGPSYCHOTHERAPY OUTCOMES

In his classic analysis, Persuasion and Healing, firstpublished in 1961 and revised in a third editionwith his daughter Julia as co-author, JeromeFrank8 argued that change in psychotherapy occurswhen factors that are common to all forms of psy-chotherapy operate in concert. His list of commonfactors included an emotionally charged confidingrelationship; the presence and encouragement ofhope; placebo effects; a healing setting; a mutuallyaccepted conceptual scheme and belief system aboutthe causes and cures of the maladies shared by bothhealer and patient; therapeutic ritual; a warm,inspiring, and socially sanctioned therapist; explo-rations of one’s inner world; opportunities forcatharsis and acquisition and practice of newbehaviors; therapeutic suggestions; and inter-personal learning. Persuasion and Healing standsas a cornerstone of scholarship into the commonfactors, and this book is required reading for allresidents in our Psychotherapy Scholars Track.

Consistent with Frank’s initial writings a largebody of research has further contributed to ourunderstanding of common factors affecting psycho-therapy outcomes, and several models using thesefactors in psychotherapy teaching have appeared.For example, the Y model9 offers an integratedmodel for teaching psychotherapy competenciesacross the 3 required schools of therapy (supportive,psychodynamic, and cognitive-behavioral thera-pies). The stem of the Y refers to the common fea-tures of psychotherapy shared across schools andincludes within it supportive therapy, whereas thebranches of the Y refer to the unique defining fea-tures of psychodynamic therapy and cognitive-behavioral therapy. According to the Y model, thecommon features across schools are alliance,assumptions about effectiveness, combined

Journal of Psychiatric Practice Vol. 21, No. 3 May 2015 181

COMMON FACTORS AFFECTING PSYCHOTHERAPY OUTCOMES


medication and psychotherapy, brief psychother-apy, and supportive therapy. In a later paper usingthe Y model, several universal factors were identi-fied that represent crucial points of teaching andlearning that are easily graspable by a residentearly in training.10 These are interviewing, for-mulation, treatment planning, alliance, frame andboundaries, listening, reflection, techniques (inter-ventions), and stages of treatment.

Although the Y model emphasizes treatmentmodalities and technique for teaching, our own designfor teaching psychotherapy led us to broadly consider6 common factors that affect psychotherapy outcomes.Although there may be room for debate as to whichcommon factor categories should be taught oremphasized, we were guided in our choices by thestrength of evidence we found in research studiesassociated with each of these factors, as documentedin Table 1. On the basis of our literature review, weselected 6 common factor categories to review: (1)patient characteristics; (2) the Hawthorne effect; (3)hope and positive expectations; (4) the therapeuticalliance; (5) therapist characteristics and behaviors;and (6) the impact of extratherapeutic events (majorexternal life events).

Patient Characteristics

The patient’s contribution to the success of psycho-therapy is substantially more important than theschool of psychotherapy, treatment method, or thetherapy relationship.11,23,26 Patient characteristicscan be invariant (eg, age, sex, birth order), rela-tively stable (eg, personality traits, socioeconomicfactors), variable (eg, motivation to change, acute-ness), or related to a particular diagnosis and rele-vant comorbid conditions, which together aretermed prescriptive factors.23 More than 161patient characteristics have been identified thatcan affect psychotherapy outcomes.1,23 Theseinclude facilitative patient variables, such ascognitive complexity, psychological mindedness,interpersonal relatedness, which contrast withinhibitory patient variables, such as poor ego func-tioning, primitive object relations, maladaptiveattachment behaviors, and personality disorders.The patient’s readiness for change is also animportant factor that is often insufficiently consid-ered when beginning treatment. Miller andRollnick’s27 simple measures of importance andcompetence, which are rated on a scale of 1 to 10, orProchaska’s stages of change28 are reasonable pre-dictors of a patient’s willingness to make changesand can be useful to monitor over the course ofpsychotherapy.

Patient characteristics that most successfullylead to change include: (1) a strongly stated desireand genuine intention to change; (2) the presence of

TABLE 1. Factors That AffectPsychotherapy Outcomes

Effective in improving psychotherapy outcomesCertain patient characteristics improve thechances for positive psychotherapy outcomes

Hawthorne effects1Hope and instilling positive expectations1Positive alliances in individual and youthpsychotherapy11,12

Positive alliances in family therapy11,12Cohesion in group therapy11,12Empathy12,13Therapist characteristics: empathy and collectingclient feedback12

Probably effective in improving psychotherapyoutcomesGoal consensus12,14Collaboration12,14

Therapist characteristic: positive regard for his orher patients14,15

Promising as effective in improving psychotherapyoutcomesTherapist characteristics: congruence/genuineness12,16 and emotional intelligence17

Therapist behaviors: repairing allianceruptures18,19 and managingcountertransference19,20

Areas for further researchAttachment pattern and the alliance21,22Psychological mindedness23Reflective functioning/mentalization24

Extratherapeutic factors affecting psychotherapyoutcomes1,25External life events (eg, marriage, a new job) canfoster a positive psychotherapy outcome

External life events (eg, trauma, loss) can lead tonegative psychotherapy outcomes




minimum obstacles to change; (3) possession ofnecessary skills and confidence to change; (4) pos-itive feelings and beliefs that change will createbenefits; (5) changes that are consistent with self-image and social norms; and (6) the presence ofreminders and encouragement from valued peoplein a supportive community or environment.29

Hawthorne Effect

The Hawthorne effect describes how workers demon-strate greater productivity when physical circum-stances under which they operate are changing, forexample, under conditions when lighting or temper-ature in a factory is altered (either increased ordecreased).30 Researchers have suggested that whatwas actually causing the increased productivity wasnot these physical changes but the fact that someonewas paying attention to the workers and observingthem as their environment changed. Similarly, psy-chotherapists from all theoretical orientations rou-tinely set up an equivalent to the Hawthorne effect,which facilitates changes in patients, to a limiteddegree, simply by virtue of the fact that they are beingobserved and listened to in an environment of undi-vided attention.1 For some patients, just the promiseof entering into a relationship in which caring andunderstanding is being offered leads to early psycho-therapeutic improvement. Far from the arbitrarychanges in the physical environment, as in the origi-nal Hawthorne effect studies, these changes in inter-personal environmental conditions help explain why apatient’s symptoms and sometimes functioning canimprove just from the process of entering into psy-chotherapy. These experiences of sharing observationsin the presence of a supportive “other” are universalexperiences in all forms of psychotherapy. Estimatessuggest that the Hawthorne effect accounts for 10% to20% of the effectiveness of psychotherapy.1,31

Hope and Positive Expectations

Generating an atmosphere of hopefulness andcommunicating expectations for positive outcomesto the patient are also important universal compo-nents present in all forms of effective psychother-apy. The positive effects of instilling hope andexpectations for recovery have also been widelydemonstrated in medicine and surgery.32,33 It is

estimated that hope and positive expectationoffered in the context of a relationship are necessarybut nonsufficient factors, and that they account forapproximately one-third of successful psychother-apy outcomes.1,31

The placebo effects of psychotherapy33–36 actuallyencompass the Hawthorne effect, hope, positiveexpectation, and other attributes34 such as a pos-itive transference. These common factors are“active” rather than “inert” placebo effects, as theycomprise important components of what makespsychotherapy work. According to Beecher’s esti-mates, “approximately 35% of a given medicaltreatment group will respond to a placebo (psycho-logical aspects) as to a medication, if the placeboeffect is a benefit derived from the expectationencouraged by the receipt of treatment and regis-tered in the form of feeling better.”33 In psycho-therapy, the act of empathically listening to asuffering patient’s symptoms and grievances willlikely help most patients feel better, by “inspiring thepatient’s hopes and combating demoralization.”8,35

Therapeutic Alliance

The greatest area of theoretical convergence amongdiverse psychotherapy schools is agreementregarding the importance of developing a strongtherapeutic alliance. According to Bordin,37 “theworking alliance is defined as being formed by theconvergence of goals, tasks, and mutual bonds.”Gelso and Hayes38 defined the alliance relationshipas “the feelings and attitudes that therapists andclients have toward one another, and the manner inwhich these are expressed.” Results of studiesassessing the importance of the alliance to treat-ment outcomes have varied depending on the defi-nition used and the quality and frequency of alli-ance measures taken over the course of treatment.According to 2 large meta-analytic reviews,39,40 thequality of the relationship between therapist andpatient accounts for 5% of the variance in outcome.A differing view, espoused by Norcross andcolleagues41–43 and Crits-Christoph et al,44 dis-counts these results as gross underestimates of theimportance of the alliance. Norcross’s critique ofthese earlier meta-analyses was that thesereviews39,40 used randomized-controlled trials thatassessed the alliance measurements only once or




twice, early in the course of a treatment episode. Inhis view, using this inadequate measurementstrategy resulted in a tendency to minimize thealliance as a central feature of the change. Crits-Christoph et al44 measured the alliance in a morefine-grained manner, using multiple patients pertherapist and measuring the alliance during aminimum of 4 treatment sessions over the course ofan entire treatment. These authors estimated thatthe quality of the relationship elements accountedfor approximately 15% of the outcome variance.Positive alliances in individual psychotherapy,positive alliances in family therapy, and cohesion ingroup therapy have all been significantly associatedwith improved psychotherapy outcomes.41

The attachment pattern of patients and therapistmay also significantly affect the working alliance.Ainsworth et al45 and Main and Weston46 identified 5major patterns of attachment: secure/autonomous,insecure anxious-resistant, insecure anxious-avoidant,disorganized/disoriented, and unclassifiable. Theseattachment patterns in adults reliably predicted thebehavior of their children in the “Strange Situation”46

(an attachment research procedure in which a child’sattachment behaviors with regard to his or herparents are observed during 20 minutes of play whilecaregivers and strangers enter and leave the room).

When adult attachment is considered in relationto the therapeutic alliance, secure attachment isassociated with positive therapeutic alliances, bothof which predict therapeutic change. Levy et al47

speculated that the capacity to develop a positivetherapeutic alliance is enhanced by a client’s levelof attachment security. Concurrently, the formationof a positive therapeutic alliance may lead to moreattachment security that leads to better psycho-therapy outcomes. Fonagy et al21 reported thatdismissive/resistant patients showed greaterimprovement in psychotherapy than preoccupied/avoidant patients. Others24 have described theopposite pattern. However, it is generally agreedthat patients showing disorganized attachment arethe most difficult to engage in a therapeutic alli-ance. Ongoing research in this area is exploringwhether the match of patient and therapistattachment styles also affects psychotherapy out-comes.22 At this point, data are insufficient todefinitively determine how important attachmentstyles are to the development of the therapeuticalliance and psychotherapy outcomes.

Therapist Variables and Behaviors: ActivitiesThat Affect Psychotherapy Outcomes

Over 27 therapist variables48 have been studied inrelation to psychotherapy outcomes, and this listcontinues to grow. Variables examined to dateinclude facilitative skill, experience, persuasiveability, genuineness, credibility, religiousness,maturity, emotional well-being, and attractiveness,among others. It is useful to categorize such traitsas those that are invariant (cannot be modified),those that are difficult to modify, and those typicalbehaviors and activities that can be more readilytaught and learned.

Nonmodifiable therapist traits include: sex, age,race, and attractiveness (although attractiveness isin the eye of the beholder and therapists can changetheir grooming and appearance to some extent).These invariant characteristics have not beenshown, in any consistent way, to have an impact onpsychotherapy outcomes. Therapist variables thatare difficult to modify but that are likely to have animpact on psychotherapy outcomes include thecapacity for empathy, the inclination to developpositive regard for patients, genuineness, andemotional intelligence (EI).

Empathy has been variably defined and oper-ationalized from study to study. Brain researchers49

have described several components of empathy: anemotional simulation process that mirrors theemotional elements of the other’s bodily experience;a conceptual, perspective-taking process50; and anemotion-regulation process49 used to soothe per-sonal distress at the other’s pain or discomfort,making it possible to mobilize compassion andhelping behavior for patients. As of yet, no clinicalstudies have used these contemporary definitions ofempathy in psychotherapy research.

Rogers51,52 and some psychoanalytic therapists53

have defined empathy as the term is used in mostresearch studies, emphasizing cognitive aspects ofempathy. To be empathic, in their definition, meansfocusing on understanding the client’s frame ofreference and ways of experiencing the world. Arecent meta-analysis,13 which involved studies thatused this specific definition, showed that empathyhad a medium effect size on psychotherapy out-come. In these analyses, the patient’s and externalobserver’s perceptions of the psychotherapist’sempathy were better able to predict outcome than




the therapist’s own perceptions of his or her ownempathy. In other words, therapists may be lesscapable of accurately observing their own empathiccapacities than are their patients or externalsupervisors. This phenomenon suggests that usingpatient and supervisor feedback about therapistempathy may be more useful than using thetherapist’s self-assessment.

Similarly, Rogers’ concepts of therapists having“positive regard” for their patients and “genuine-ness” have both been studied15,16 and they havebeen found to be associated with significant bene-ficial effects on psychotherapy outcomes.

EI includes the ability to identify, assess, andcontrol one’s emotions, whereas also accuratelyreading and effectively managing the emotions ofothers and groups. The results of a pilot study17

suggested that this set of skills may be associatedwith positive psychotherapy outcomes. In this smallpreliminary study, therapists with higher ratings ofEI achieved better therapist-rated outcome resultsand lower dropout rates compared with therapistswith lower ratings of EI. Higher therapist EI wasalso significantly associated with increased patient-assessed treatment compliance.

Little research is available that clearly demon-strates effective ways to teach empathy better,improve the development of positive regard forpatients, or enhance EI. However, teachers canmodel these behaviors clinically and show that theyvalue them. Decreasing the stress of the work envi-ronment may increase empathy. Teaching culturalcompetence may also have an impact on developingpositive regard for a broad array of patients. Thera-pist behaviors and activities that can be modified ortaught and that also affect psychotherapy outcomesare being studied. Two clinical activities that havebeen shown to improve outcomes are establishingtherapeutic goals with the patient and collaboratingwith the patient to work on those goals. When apatient and therapist agree upon “consensus goals”14

(eg, establishing a therapeutic contract and goals),psychotherapy outcomes improve. In a recent meta-analysis of 15 studies,14 the effect of goal consensuson psychotherapy outcome was small, but significant.Although agreeing on common treatment goals isimportant, it is also important that the therapist andpatient collaborate in meeting their consensus goals.A second meta-analysis that examined 19 studies14

showed that using collaborative measures, such as

the working alliance, compliance scales, and home-work completion, showed a small but significanteffect size for collaboration as a variable thatimproves psychotherapy outcomes. A meta-analysisof 4 studies14 found an effect size between small andmedium, demonstrating a positive relationshipbetween goal consensus and collaboration, and psy-chotherapy outcomes.

Although estimates show that up to 65% of patientsimprove substantially from psychotherapy,31 an esti-mated 5% to 10% of adults in clinical psychotherapytrials actually get worse. This number is even higher inchild and adolescent populations.54 Although deterio-ration in patient functioning during treatment is oftenattributed to external life events, therapists must alsoattend to their own potential contributions to apatient’s decision to drop out of treatment. Three spe-cific therapist behaviors that can reduce adverse psy-chotherapy outcomes can be taught and learned. Theseinclude collecting client feedback, repairing allianceruptures, and managing countertransferences.

The utility of collecting patient feedback forimproving outcomes depends on the discrepancybetween the patient’s and the therapist’s view of thetreatment. Greater patient-therapist disagreementabout how helpful treatment has been providesgreater opportunity to initiate corrective practicesand to reestablish successful treatment.54 Feedbackto therapists is most useful when the therapists arecommitted to improving their performances. Get-ting patient feedback provides an opportunity forthe motivated therapist to do a “kick save” of atreatment going badly. Several methods forobtaining and providing feedback in a psychother-apy context are described elsewhere.55

An alliance rupture is defined as a “breakdownin the collaborative relationship between patientand therapist.”18 Repairing ruptured alliances isextremely important, both to prevent unwanted ter-minations and to improve psychotherapy outcomes.Viewed through the lens of Bordin’s37 definition ofthe alliance, quoted earlier, relationship ruptures canbe described as disagreements about treatment goals,tasks, or stresses in the patient-therapist relation-ship. Problems in the working alliance often occurwhen the patient believes the therapist is missingsomething important or has been insensitive orinsulting. Common rupture repairing techniques thatcan be taught include repeating the reason for thetherapy; modifying the tasks or goals of the




treatment; clarifying the current misunderstanding;exploring the transference, past relationships, andlife themes that are affecting the therapeutic rela-tionship; and providing a new model for a new rela-tionship.18 In a recent meta-analysis by Safranet al,18 the presence of rupture-repair episodes wasassociated with a moderate effect size in promotingpositive treatment outcomes. In a different meta-analysis of 8 studies by the same authors,18 theimpact of rupture resolution training or supervisionon patient outcomes was also positive, demonstratinga large pre-post effect size. Both meta-analyseshighlight the fact that repairing and preserving thealliance, in all forms of treatment, will tend toimprove psychotherapy outcomes.

Countertransference has been defined in multipleways. Freud initially described countertransference asrepresenting unwanted reactions to the patient basedon the therapist’s unresolved conflicts.56 Counter-transference in this definition can be managed bydiscussions with supervisors, treating cliniciansworking on these issues in their own treatment, or, asin our program, by discussing these issues in a weeklycountertransference group designed specifically forresidents and led by senior faculty. More recentbroader conceptions called “global counter-transferences”57 refer to therapists’ reactions tounconscious communications engendered by thepatient’s use of projection and projective identification.Global countertransferences often cannot be avoided,and, in fact, they can be used as valuable informationabout how the patient affects others globally. How-ever, from the research perspective,20 counter-transference as originally defined by Freud has beenstudied and needs to be corrected or managed so thatthe therapist’s unwanted reactions do not adverselyaffect psychotherapy outcome. A meta-analysis of 7studies that used Freud’s definition and a well-vali-dated version of the Countertransference FactorInventory58 found that countertransference manage-ment resulted in significant and large effects inenhancing psychotherapy outcomes. The clinicalimplications for all forms of psychotherapy are worthconsidering. Countertransference matters, and it mayhave a greater impact on various forms of psycho-therapy across the board than specific schoolsof psychotherapy often acknowledge. Psychotherapistscan likely improve their outcomes by managing andacknowledging their maladaptive countertransferencereactions as part of repairing ruptured alliances.

Perhaps more than any other common factor,modifiable therapist variables can help residents intraining maximize their influence and feel com-petent. Collecting client feedback, repairing allianceruptures, and managing countertransferences arefactors woven into more than 1 common factor cat-egory. They affect the patient’s subjective sense of theHawthorne effect, sense of hope, and the alliance.

Extratherapeutic Factors AffectingPsychotherapy Outcomes

Estimates suggest that extratherapeutic effects, orlife events, have greater impact on psychotherapyoutcomes than all of the other single factors thataffect outcome.1,25,59 Life events can serve as turningpoints that can close or open treatment opportunities,create a lasting change in the person’s environment,or change a person’s self-concept, beliefs, and expect-ations.59 The effect of life events on psychotherapyoutcomes is most important to consider when treat-ments do not proceed as expected. External life eventscan accelerate expected improvements or, conversely,can lead to partial success, dropouts, or treatmentfailures. From a therapist-centric vantage point, it iscrucial to remember the effects of extratherapeuticfactors as this can help restrain our grandiosity whentaking too much credit for the success of psychother-apy or, alternatively, help us avoid accepting inaccu-rate or excessive blame for some treatments that fail.

PRINCIPLES OF TEACHING: COMMONFEATURES OF ALL PSYCHOTHERAPIES

In educating new therapists or psychiatric resi-dents, we believe that emphasizing common factorsof psychotherapy is preferable to initially focusingon specific schools or specific theories of psycho-therapy. On the basis of our review of the literature,we derived 8 principles that guide our teachingabout common factors:

(1) Teach patient-centered psychotherapy, focusingon the patient’s needs, problems, diagnosis, orfunctional capacity. Do not focus initially on aschool or theory of psychotherapy.

(2) Work toward using a common language for all ofpsychotherapy, which describes common clinicalphenomena. The corollary: help students




understand how different schools of psychother-apy, which use totally different languages,describe similar clinical phenomena. For example,the concept of “resistance” in psychodynamictherapy is called “treatment interfering behavior”in dialectical behavioral therapy. The psycho-analytic concept of internalized object relationsis similar to concepts used in schema-focusedtherapy.

(3) Acknowledge how all schools of psychotherapyhave borrowed or modified useful concepts fromone another; stop reinforcing the notion propa-gated by new schools of psychotherapy that theyhave discovered something brand new, when, infact, they most often keep reinventing a similarwheel with occasional improvements—lots of oldwine in new packaging.

(4) Tailor the psychotherapy for individualpatients, utilizing specific interventions thattarget precise patient needs, diagnosis, prob-lems, or other aspects of patient functioning foreach episode of treatment.

(5) Develop criteria for selecting an appropriatecontext for treatment, starting with considera-tions regarding whether individual, group, and/or family/systemic treatment is appropriate.

(6) Begin teaching psychotherapy by choosing a broadtreatment modality that utilizes many commonfactors, such as crisis intervention, supportivepsychotherapy, group, or family therapy. Thesetreatments may be among the best clinicalstrategies for fostering awareness of commonfactors, psychotherapy outcomes, and the clinicalintegration of school-specific psychotherapies.

(7) Teach the different major and traditional formsof psychotherapy later in training, emphasizingwhat they have in common and their differ-ences, and illustrating how some individualforms of treatment can be modified for groupor family treatments.

(8) Teach the comparative effectiveness of empiri-cally supported treatments for specific patients,conditions, or problems.2

DISCUSSION

We reviewed 6 well known and widely researchedcommon factors in psychotherapy: (1) patient char-acteristics; (2) the Hawthorne effect; (3) hope and

positive expectations; (4) the therapeutic alliance;(5) therapist characteristics and behaviors; and (6)extratherapeutic variables. These factors led us toformulate and implement foundational principlesfor education and clinical practice in our psycho-therapy training program. These principles enabletherapists to focus better on their clients’ needs andto better understand the commonalities and differ-ences among and between different schools of psy-chotherapeutic thought. Learning common factorsearly in training allows our therapists/residents totailor their treatment modalities to patient needs asthey move from the common factors approach tolearning more specific schools of psychotherapylater in their training.

CONCLUSIONS

This article reviewed common factors that fosterpositive psychotherapy outcomes. The commonfactors approach led us to make specific recom-mendations for teaching and psychotherapy train-ing. As Castonguay60 observed: “The assumptionthat building on plurality and convergences canimprove psychotherapy outcome is based on twoobvious premises: that this type of rapprochementcan widen the scope of our understanding and therepertoire of our practice, as well as increase ourconfidence in interventions or constructs that aresupported by different perspectives of knowledge.”Laska et al19 also argued that a common factorsapproach improves quality assurance by facilitatingbetter training, feedback, alliance, and therapistvariables. We believe that this approach allowstherapists/psychiatric residents to become moreeffective and confident early in their training.

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Common factors affecting psychotherapy outcomes: some implications for teaching psychotherapy

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