Common factors: What makes psychotherapy work?

Common Factors in Psychotherapy

There are many reasons why therapy is helpful. A fresh perspective, particular skills, expertise in the various things that ail people…all of these change agents make sense. But research suggests that these skills are not in and of themselves the true mechanisms of change in psychotherapy.

In fact, there is an overarching set of factors that create the benefit in psychotherapy, pathways that are common to all established psychotherapeutic models. They work precisely because humans are social, and psychotherapy heals through social contact.

According to researcher Bruce Wampold (2015) the common factors of psychotherapy can be understood as the development of a relationship, the creation of expectations of change and the establishment of health promoting behaviors.

Relationship: Wampold reminds us that the first order of business in psychotherapy is the establishment of relationship and the exploration of the therapeutic alliance. This bond is critical, and takes time, but some of it happens very quickly and to some extent outside of our conscious awareness. How? The same way it does in any other arena of life—we rapidly and implicitly take in style of dress, mannerisms, voice quality, even office décor and use these things to make judgments and the critical assessment of goodness of fit.

In my professional judgment, the relationship between therapist and client is perhaps the most critical feature of treatment. It is a human connection, and just as we don’t connect with everyone we meet, we cannot expect to connect with every psychologist. For this reason, I always encourage new potential clients to interview several people when choosing a psychologist.

Expectations: Wampold tells us that a person’s expectations for treatment have a huge impact on treatment outcome. Sometimes people arrive with a ‘last ditch’ attitude, the sense they’ve tried everything else and, having reached the bottom of their personal barrel are now subjecting themselves to the scrutiny of a stranger. Other times, people arrive with an expectation that together with their psychotherapist they’ll explore what has and has not worked in their lives, and come up with new solutions to old challenges. Perhaps these people are arriving with similar challenges—they are likely to have very different notions about what psychotherapy is about.

I firmly believe that we as a species are growth oriented, even when demoralization has led us to forget that fact. I also believe that people’s symptoms are not just signs of problems, they are representative of best efforts at coping and change. I think goal setting is critical to progress in treatment, and a collaborative effort that clearly places the locus of change where it belongs—in the middle of the treatment alliance, surrounded by the tasks and rituals of psychotherapy.

Tasks and Rituals: And what are the tasks and rituals of psychotherapy? That very much depends on the nature of the problem, the individual’s goals, and the background of the clinician. Regardless of the details, each task of therapy is focused in one way or another on what Wampold calls “salubrious actions.” The treatment alliance allows trust, and gives a person room to think about his or her world in new ways, to consider thoughts and feelings from a different point of view, to experiment with new ways of being in the world and to collaborate with the trusted other on the mechanisms of change.

But the heart of the entire endeavor is the treatment relationship. So when you are looking for a psychologist, consider goodness of fit as carefully as you do any other quality.

Wampold, B.E. (2015). How important are the common factors in psychotherapy? An update. World
       Psychiatry, 14(3).
270-277.