Psychotherapy 2014, Vol. 51, No. 4, 496 – 499
© 2014 American Psychological Association 0033-3204/14/$12.00 DOI: 10.1037/a0036540
COMMENTARY
Welcome to the Party, But . . . Larry E. Beutler
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.
Palo Alto University Laska, Gurman, and Wampold (2014, pp. 467– 481) argue for the inclusion of common factors (CF) approaches to psychotherapy to be an alternative to empirically supported therapies when developing an evidence-based practice. Although we applaud their scholarship and the cogency of their arguments, we believe that they fall short of what is needed to define an optimal and effective therapy. Integration rather than amalgamation better captures the complexity of psychotherapy and adds to the explained variance. While CF dimensions certainly should be considered within the research definition of “psychotherapy,” there are also important characteristics of the participants that are not captured in either the patient’s diagnosis or the interventions that the therapist uses that affect outcome. We believe that the authors have inadvertently equated CFs with nonspecific ones and thus excluded a host of moderating variables in psychotherapy that produce specific and differential effects but which are not “nonspecific.” Keywords: common factors, empirically supported treatments, evidence-based practice, psychotherapy integration, psychotherapy outcome
30 years (Beutler, 2009; Budd & Hughes, 2009; Goldfried, 1980; Norcross, 2011). Like CF theorists, integrative psychotherapy research arose from the observations that the various brands of psychotherapy yield similar results and that some patients in all therapies get better, get worse, or stay the same. These observations led some to look for what was common among the various approaches (e.g., the CF approach), while others initially began by searching for the differences among them (the integrationist approach). Both groups came to have a poor regard for the distinctiveness of various brand names of psychotherapy and continue to place little faith in the contemporary definitions of “empirically supported treatments” (Chambless & Hollon, 1998), grounded as they are in a tradition of randomized clinical trial (RCT) research. Wampold’s (2001) book, The Great Psychotherapy Debate, and a long list of supporting research (Wampold et al., 1997; Wampold & Budge, 2012) have provided a virtual bible in support of the presence of CFs that contribute to psychotherapy outcomes. This collective work clearly confirms that therapy brands contribute little to our understanding of specific or differential outcomes, accounting for less than 10% of attributed change (Norcross & Lambert, 2006). The development of modern integrationist perspectives has been more convoluted than that of the CF perspective. Integrationism developed out of early research that attempted to identify either brands of intervention or menus of techniques that optimized treatment fit with different types and diagnoses of patients (Beutler, 1983; Lazarus, 1967). However, the futility of this technical eclectic approach rapidly became apparent to many when wide variations were observed to exist both in how different therapists applied the same procedures and how any given procedure affected different patients. Although the popularity of technical eclecticism has declined among integrationists, the interest in matching patients with treatments has not and is the distinguishing feature of the integrative movement.
Laska, Gurman, and Wampold (2014, pp. 467– 481 remind us that empirically supported treatments (ESTs) should not be equated with evidence-based practice (EBP). They demonstrate that EST research has several weaknesses that should encourage those who plan to implement an evidence-based program to broaden their views beyond ESTs. Most notably, the authors review an extensive body of literature to demonstrate that: (a) ESTs are rarely found to yield unique or distinctive outcomes when compared with one another, (b) ESTs have failed to demonstrate the specific population effects to which they aspire (i.e., anxiety treatments work about as well for depression or life adjustment disorders as they do for anxiety), (c) the effects of ESTs are essentially equivalent to treatment as usual, (d) the mechanisms of action postulated by the theories underlying ESTs generally have not been confirmed, and (e) common factors (CF) interventions are at least as powerful as ESTs but may significantly increase overall effect sizes. We agree with Laska and colleagues (2014) in suggesting that the data are overwhelming on these five points. But, we wish to add two substantial caveats to their conclusions: (a) their admonitions are not new and (b) they do not go far enough.
A Search for Integration Not Simply Amalgamation The idea of combining CFs and unique or distinctive contributors to change has been argued by numerous authors for more than
Larry E. Beutler, Pacific Graduate School of Psychology, Palo Alto University. Correspondence concerning this article should be addressed to Larry E. Beutler, 2620 Piedra Verde Court, Placerville, CA 95667. E-mail: [email protected] 496
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.
COMMON FACTORS—COMMENT
Electing not to be confined to the study of brand-named interventions and patient diagnoses as grist for the treatment-matching mill, and spurred by the work of Goldfried (1980), Prochaska (1979), and colleagues (Prochaska & DiClemente, 1982), in the mid-1980s, integrative investigators began to identify a set of principles or strategies that would identify and bring the effects of relationship, participant, and contributors to treatment–patient “fit” into a cohesive and cross-cutting perspective. These principles include but are not restricted to the inclusion of CFs as mediators of change; they also include the identification of cross-cutting moderators of change in an effort to fill out the picture of effective psychotherapy. With the concern that the CF perspective inaccurately equated “common factors” with “nonspecific” ones in producing change, integrationists began looking to cross-cutting dimensions that were differentially associated with specific change. For example, Beutler and Clarkin (1990) combined their early and overlapping technical eclectic efforts (Beutler, 1983; Frances, Clarkin, & Perry, 1984) into a more comprehensive system that incorporated the predictive power of patient (diagnostic and nondiagnostic) factors, settings and contexts, relationship qualities, and specific modes and formats of treatment as well as discrete classes of interventions. Beginning with a comprehensive review of the psychotherapy literature on specific effects, they derived a list of more than 40 variables that exerted a notably mediating and often differential or “moderating” effect on outcomes. These variables included relationship factors, therapist and patient factors, and contexts, drawing from CF, persuasion research, and RCT research. From this list, they proposed a system of cross-cutting treatment planning principles that fit specific patients to particular therapeutic styles and classes of intervention. Ten years later, these authors collaborated again (Beutler, Clarkin, & Bongar, 2000) to: (a) update their earlier literature review; (b) refine the list of predictors by reducing overlap and sharpening the criteria for inclusion; (c) develop measures of the relevant participant, contextual, and treatment variables that comprised predictors from their review of literature; and (d) conduct a crossvalidation study of the direct and moderating effects of the resulting groups of variables on outcomes among a large sample of mixed patients. Out of this effort, 18 principles that characterized optimally effective psychotherapy and psychotherapy fit were defined, consensually validated, and cross-validated. These principles reflected the actions of a broad array of both mediators and moderators of change. They included aspects of the relationship, aspects of patient risk and severity as well as coping style and resistance level, and therapist behaviors associated with personal style and selective interventions. Recognizing that the principles defined by one group may lack consensual validity for another, Castonguay and Beutler (2006) convened a task force sponsored jointly by the North American Society for Psychotherapy Research and Division 12 of the American Psychological Association. This task force was charged with independently reviewing extant psychotherapy literature with an eye toward constructing an independent list of cross-cutting principles on which comprehensive interventions could be built. A panel of 24 distinguished scholars, representing multiple theoretical perspectives, were selected, recruited, and assigned to work in contrasting pairs (assisted by 21 coauthors of their choice), to review the psychotherapy literature focusing on treatment of four
497
diagnostic groups (depression, anxiety, chemical abuse, and personality disorder) and within three domains of influence (participant factors, interventions, and relationships/contexts). They initially distilled the literature in their assigned area into a series of principles that they concluded were empirically established. A consensus meeting of authors reduced the list to 61 principles, 26 that were identified in more than one of the four problem areas (common principles) and 35 that had been identified in only one of the problem areas (unique principles). The nomenclature adopted by Castonguay and Beutler (2006) illustrates an important distinction between how the terms “common” and “specific” are used in an integrative context and how it is used in the CF literature. Table 1 illustrates this difference. This table provides a list of eight principles, extracted and somewhat reworded from the original Castonguay and Beutler list of 61. These eight principles are currently being used by my colleagues and me (Beutler et al. 2014) as the foundation for learning psychotherapy in a university clinic that trains PhD and PsyD students. Principles 2, 3, and 4, will probably be recognized by CF advocates as reflecting “common” factors. The other principles, however, are generally ignored by CF and RCT researchers. Nonetheless, from an integrated perspective, all the principles are “common” in that they apply equally to various theory-based models of psychotherapy. The difference is that to the integrationist, Principles 1, 5, 6, 7, and 8 address the role of moderators, and unlike the CF, “common factors” predict a patient by treatment differential effect on treatment outcome. Although CF and integrative advocates may differ in what they view as constituting “common” factors, as one articulates the essence of psychotherapy from these two perspectives, it quickly becomes clear that these two groups of researchers share a common interest in encouraging the use of a broad set of methodologies to uncover optimal fits of contexts, participants, and interventions. This perspective contrasts with those who define psychotherapy by the interventions alone and who, in so doing, view randomized clinical trials as a gold-standard methodology. This observation led Beutler (2009; Beutler & Forrester, 2014) and others (Norcross, 2011) to advocate a more inclusive research definition of psychotherapy than that advocated by EST researchers (Baker, McFall, & Shoham, 2008). These scholars advocate expanding the list of variables studied and the research methods accepted as evidence of “empirical support” to converge on the underlying interplay of effective psychotherapy processes. This recommendation has been accompanied by a series of demonstrations (Beutler, 2009; Beutler, Forrester, Gallagher-Thompson, Thompson, & Tomlins, 2012) that illustrate how classes of interventions (rather than therapy brands) combine with participant factors (e.g., patient personalities and therapist skill, therapist helpfulness, preferences, and interpersonal relationships) to evoke change. These participant factors often cannot be randomly assigned, but nonetheless have proven themselves in abundant research literature (Garfield, 1980; Norcross, 2011) to be variables that interact with interventions to produce change. This approach has confirmed the view that psychotherapy is more than a list of additive variables drawn from CF and RCT traditions, but is an interactive and complementary cluster of intersecting mediating and moderating variables that complement one another to enhance change (Beutler et al., 2003; Beutler et al., 2012).
BEUTLER
498
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.
Table 1 Principles of Therapeutic Change—An Example Impairment-level principle. 1. For all patients with moderate to severe impairment, the therapist should identify social service or medical care needs and arrange for attention to these needs. Those with low social support systems, in particular, need assistance from the therapist to develop social support and support services. This may mean the use of adjunctive group or multiperson interventions. Relationship principles. Three principles draw the supervisors’ and students’ attention to the importance of the therapeutic relationship in effecting change. 2. Therapy is likely to be beneficial if a strong working alliance is established and maintained during the course of treatment. 3. The qualities of a good working alliance are likely to be facilitated if the therapist relates to clients in an empathic way; adopts an attitude of caring, warmth, and acceptance; and adopts an attitude of congruence or authenticity. 4. Therapists are likely to resolve alliance ruptures when addressing such ruptures in an empathic and flexible way. Resistance principles. One principle describes the central role of varying one’s approach when client resistance is encountered. 5. In dealing with the resistant client, the therapist’s use of directive therapeutic interventions should be planned to inversely correspond with the patient’s manifest level of resistant traits and states. Nonconfrontational strategies are most helpful in working with such clients. Coping-style principles. Ways that clients cope with change affect the goals that optimally guide psychotherapy. Two principles define this relationship. 6. Clients whose personalities are characterized by relatively high “externalizing” styles (e.g., impulsivity, social gregariousness, emotional liability, and external blame for problems) benefit more from direct behavioral change and symptom reduction efforts, including building new skills and managing impulses, than they do from procedures that are designed to facilitate insight and self-awareness. 7. Clients whose personalities are characterized by relatively high “internalizing” styles (e.g., low levels of impulsivity, indecisiveness, selfinspection, and overcontrol) tend to benefit more from procedures that foster self-inspection, self-understanding, insight, interpersonal attachments, and self-esteem than they do from procedures that aim at directly altering symptoms and building new social skills. Readiness principle. Client readiness and receptivity are important qualities, but patients differ widely in these qualities. Stages of readiness that predict treatment effects have been identified. 8. Clients who are in more advanced stages of readiness for change (e.g., preparation, action, and maintenance) are more likely to improve in psychotherapy than those at lower stages of readiness (pre-contemplation and contemplation).
This integrative view is gaining ground among others who view contemporary EBP and EST research to be unnecessarily and inappropriately narrow. Recently, a group of 19 senior scholars (Holt et al., 2013), all whom are either past presidents of Divisions 29, 12, and 50 of the American Psychological Association, past presidents of the North American Society for Psychotherapy Research, or past presidents of the (international) Society for Psychotherapy Research, called on the Department of Veterans Affairs Health Care Systems to expand the criteria by which EBPs are identified in their system to include evidence drawn from methodological alternatives to RCT designs and that incorporates CF and integrative constructs into practice. Beutler and Forrester (2014) reinforced this view by outlining and illustrating a way to incorporate CF and integrationist research into most RCT designs to facilitate an understanding of the complexity of change. With these developments, the path is being paved for a future that could include agreements on multiple fronts among investigators and practitioners.
The Future of Integrative and CF Perspectives While not a soothsayer, I continue to believe that the future belongs to the broad, not the narrow, thinkers. An inclusive view will, in the end, give us the greatest ability to help others. Whether that view will fully integrate CF, integrationist, and RCT views or will be a more limited amalgamation such as that proposed by Laska et al. (2014) is not clear. We scientists are bound, as are all humans, to fight to maintain our beliefs intact, even if it means denying and rejecting even well-validated views of others, as long as we can find a smattering of evidence that will allow us to do so. But, there is one thing that we could collectively do, that would open the door to a science of psychotherapy more than any other. We could agree that the effects of psychotherapy have many
determinants and, therefore, are best studied via a multiplicity of rigorous methods. To advance, I believe that we must assume this broad view rather than adhering to an archaic “gold” standard that defines “science” solely through the lens of an RCT methodology. If the capacity to be randomly assigned is the only criterion that truly matters in determining what is and is not a science, neither astrophysics or climatology, nor for that matter classical physics or chemistry, would be considered “scientific.” We would still live in a heliocentric universe, walking on a flat earth, and denying human influences in climate change. Indeed, it is decidedly “unscientific,” in our view, to define science by one’s use of a single research methodology. Science thrives when it is multidimensional and is left behind if it does not develop methods of measuring and gathering evidence from multiple methods and perspectives. By opening the door to multiple methodologies and openly acknowledging that psychotherapy influence is not a simple matter of identifying and applying interventions, I believe the appeal of psychotherapy would be enhanced. I think those who are recipients of effective psychotherapy understand that the essence of its effects relies on the discriminant use of participant factors, both therapist and patient, as well as contextual factors, interventions, and authentic relationships, to achieve an optimal fit of factors that promote beneficial change. Making a decision simply to broaden our definition of acceptable methods would take us beyond the limitations imposed when we restrict our attention to diagnosis and therapist orientation. In short, if psychotherapy research groups would all accept the simple proposition that good science incorporates the strengths of multiple methods, it would encourage research to determine if an integration, as proposed here, or an amalgamation between treatment-specific interventions and CFs, as proposed by Laska et al. (2014), best fits the aims of improved prediction and control.
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.
COMMON FACTORS—COMMENT
The selective and progressive use of multiple methods allows one to partial the influence of contributors to change in ways that can increase the likelihood of beneficial gains substantially through treatment selection and application (Beutler & Forrester, 2014; Beutler, 2009; Beutler et al., 2003). Finally, such a shift of perspective would allow us to acknowledge what we already accept in practice, namely that psychotherapy involves a much larger array of activities and constructs than that which is defined by our techniques and brands of intervention. As a demonstration of where such a broad view of psychotherapy may lead, Constantino, Castonguay, and Beutler (2014) are currently refining the principles originally articulated by Castonguay and Beutler (2006), reducing overlap, confirming their status as common or specific predictors, and testing them against a standard criteria of empirical validity. In a final step, they are asking practicing therapists to help us identify how these principles would and could be used in their own practices. Although this is still a work in progress, three things are already clear: (a) the list of empirically supported principles of change will include representatives of participants, interventions, and contexts/relationships; (b) a relatively small number of principles can be articulated that will capture the variety that is psychotherapy; and (c) by far the preponderance of these principles describes effects that are “common” across brands of intervention and diagnostic groups. Although subject to change as our research progresses, about one-third of the empirically supported principles of change pertain to the use of differential interventions (i.e., moderators of change) and the rest reflect on participant and relationship factors that mediate change. Psychotherapy of the future may look at how principles of change interface with one another rather than being consolidated around horse races among different brands of intervention.
References Baker, T. B., McFall, R. M., & Shoham, V. (2008). Current status and future prospects of clinical psychology: Toward a scientifically principled approach to mental and behavioral health care. Psychological Science in the Public Interest, 9, 67–103. Beutler, L. E. (1983). Eclectic psychotherapy: A systematic approach. New York, NY: Pergamon Press. Beutler, L. E. (2009). Making science matter in clinical practice: Redefining psychotherapy. Clinical Psychology: Science and Practice, 16, 301– 317. doi:10.1111/j.1468-2850.2009.01168.x Beutler, L. E., & Clarkin, J. F. (1990). Systematic treatment selection: Toward targeted therapeutic interventions. New York, NY: Brunner/ Mazel. Beutler, L. E., Clarkin, J. F., & Bongar, B. (2000). Guidelines for the systematic treatment of the depressed patient. New York, NY: Oxford University Press. doi:10.1093/acprof:oso/9780195105308.001.0001 Beutler, L. E., & Forrester, B. (2014). What needs to change: Moving from “research informed” practice to “empirically effective” practice. Journal of Psychotherapy Integration, 24, 168 –177. doi:10.1037/a0037587 Beutler, L. E., Forrester, B., Gallagher-Thompson, D., Thompson, L., & Tomlins, J. B. (2012). Common, specific and treatment fit variables in psychotherapy outcome. Journal of Psychotherapy Integration, 22, 255– 281. doi:10.1037/a0029695 Beutler, L. E., Kimpara, S., Haug, N., Macias, S., Shiloff, N., & Goldblum, P. (2014). Enhancing Psychotherapy Training with the use of STS/ Innerlife Feedback in Supervision at the Gronowski Center. A research
499
program in progress. Unpublished manuscript, Palo Alto University, Palo Alto, CA. Beutler, L. E., Moleiro, C., Malik, M., Harwood, T. M., Romanelli, R., Gallagher-Thompson, D., & Thompson, L. (2003). A comparison of the Dodo, EST, and ATI indicators among co-morbid stimulant dependent, depressed patients. Clinical Psychology and Psychotherapy, 10, 69 – 85. doi:10.1002/cpp.354 Budd, R., & Hughes, I. (2009). The dodo bird verdict— controversial, inevitable and important: A commentary on 30 years of meta-analyses. Clinical Psychology and Psychotherapy, 16, 510 –522. doi:10.1002/cpp .648 Castonguay, L. G., & Beutler, L. E. (Eds.). (2006). Principles of therapeutic change that work: Integrating relationship, treatment, client, and therapist factors (Vol. I). New York, NY: Oxford University Press. Chambless, D. L., & Hollon, S. D. (1998). Defining empirically supported therapies. Journal of Consulting and Clinical Psychology, 66, 7–18. doi:10.1037/0022-006X.66.1.7 Constantino, M., Castonguay, L. G., & Beutler, L. E. (Eds.). (2014). Principles of psychotherapy that work: Applications (Vol. II). Manuscript in preparation. New York, NY: Oxford University Press. Frances, A., Clarkin, J., & Perry, S. (1984). Differential therapeutics in psychiatry. New York, NY: Brunner/Mazel. Garfield, S. L. (1980). Psychotherapy: An eclectic approach. New York, NY: Wiley. Goldfried, M. R. (1980). Toward the delineation of therapeutic change principles. American Psychologist, 35, 991–999. doi:10.1037/0003066X.35.11.991 Holt, H., Beutler, L. E., Castonguay, L. G., Silberschatz, G., Forrester, B., Temkin, R., . . . Miller, T. W. (2013). A critical examination of the movement toward evidence-based treatments in the U.S. Department of Veterans Affairs. The Clinical Psychologist, 66, 8 –12. Laska, K. M., Gurman, A. S., & Wampold, B. E. (2014). Expanding the lens of evidence-based practice in psychotherapy: A common factors perspective. Psychotherapy, 51, 467– 481. doi:10.1037/a0034332 Lazarus, A. A. (1967). In support of technical eclecticism. Psychological Reports, 21, 415– 416. Norcross, J. C. (Ed.). (2011). Psychotherapy relationships that work: Therapist contributions and responsiveness to patient needs (2nd ed.). New York, NY: Oxford University Press. doi:10.1093/acprof:oso/ 9780199737208.001.0001 Norcross, J. C., & Lambert, M. J. (2006). The therapy relationship. In J. C. Norcross, L. E. Beutler, & R. F. Levant (Eds.), Evidence-based practices in mental health: Debate and dialogue on the fundamental questions (pp. 208 –218). Washington, DC: American Psychological Association. doi: 10.1037/11265-000 Prochaska, J. O. (1979). Systems of psychotherapy: A transtheoretical analysis. Homewood, IL: Dorsey. Prochaska, J. O., & DiClemente, C. C. (1982). Transtheoretical therapy: Toward a more integrative model of change. Psychotherapy: Theory, Research, and Practice, 19, 276 –288. doi:10.1037/h0088437 Wampold, B. E. (2001). The great psychotherapy debate: Models, methods, and findings. Mahwah, NJ: Erlbaum. Wampold, B. E., & Budge, S. L. (2012). The 2011 Leona Tyler Award address: The relationship–and its relationship to the common and specific factors of psychotherapy. The Counseling Psychologist, 40, 601– 623. doi:10.1177/0011000011432709 Wampold, B. E., Mondin, G. W., Moody, M., Stich, F., Benson, K., & Ahn, H. (1997). A meta-analysis of outcome studies comparing bona fide psychotherapies: Empirically, “All must have prizes”. Psychological Bulletin, 122, 203–215. doi:10.1037/0033-2909.122.3.203
Received February 3, 2014 Accepted February 4, 2014 䡲
© 2014 American Psychological Association 0033-3204/14/$12.00 DOI: 10.1037/a0036540
COMMENTARY
Welcome to the Party, But . . . Larry E. Beutler
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.
Palo Alto University Laska, Gurman, and Wampold (2014, pp. 467– 481) argue for the inclusion of common factors (CF) approaches to psychotherapy to be an alternative to empirically supported therapies when developing an evidence-based practice. Although we applaud their scholarship and the cogency of their arguments, we believe that they fall short of what is needed to define an optimal and effective therapy. Integration rather than amalgamation better captures the complexity of psychotherapy and adds to the explained variance. While CF dimensions certainly should be considered within the research definition of “psychotherapy,” there are also important characteristics of the participants that are not captured in either the patient’s diagnosis or the interventions that the therapist uses that affect outcome. We believe that the authors have inadvertently equated CFs with nonspecific ones and thus excluded a host of moderating variables in psychotherapy that produce specific and differential effects but which are not “nonspecific.” Keywords: common factors, empirically supported treatments, evidence-based practice, psychotherapy integration, psychotherapy outcome
30 years (Beutler, 2009; Budd & Hughes, 2009; Goldfried, 1980; Norcross, 2011). Like CF theorists, integrative psychotherapy research arose from the observations that the various brands of psychotherapy yield similar results and that some patients in all therapies get better, get worse, or stay the same. These observations led some to look for what was common among the various approaches (e.g., the CF approach), while others initially began by searching for the differences among them (the integrationist approach). Both groups came to have a poor regard for the distinctiveness of various brand names of psychotherapy and continue to place little faith in the contemporary definitions of “empirically supported treatments” (Chambless & Hollon, 1998), grounded as they are in a tradition of randomized clinical trial (RCT) research. Wampold’s (2001) book, The Great Psychotherapy Debate, and a long list of supporting research (Wampold et al., 1997; Wampold & Budge, 2012) have provided a virtual bible in support of the presence of CFs that contribute to psychotherapy outcomes. This collective work clearly confirms that therapy brands contribute little to our understanding of specific or differential outcomes, accounting for less than 10% of attributed change (Norcross & Lambert, 2006). The development of modern integrationist perspectives has been more convoluted than that of the CF perspective. Integrationism developed out of early research that attempted to identify either brands of intervention or menus of techniques that optimized treatment fit with different types and diagnoses of patients (Beutler, 1983; Lazarus, 1967). However, the futility of this technical eclectic approach rapidly became apparent to many when wide variations were observed to exist both in how different therapists applied the same procedures and how any given procedure affected different patients. Although the popularity of technical eclecticism has declined among integrationists, the interest in matching patients with treatments has not and is the distinguishing feature of the integrative movement.
Laska, Gurman, and Wampold (2014, pp. 467– 481 remind us that empirically supported treatments (ESTs) should not be equated with evidence-based practice (EBP). They demonstrate that EST research has several weaknesses that should encourage those who plan to implement an evidence-based program to broaden their views beyond ESTs. Most notably, the authors review an extensive body of literature to demonstrate that: (a) ESTs are rarely found to yield unique or distinctive outcomes when compared with one another, (b) ESTs have failed to demonstrate the specific population effects to which they aspire (i.e., anxiety treatments work about as well for depression or life adjustment disorders as they do for anxiety), (c) the effects of ESTs are essentially equivalent to treatment as usual, (d) the mechanisms of action postulated by the theories underlying ESTs generally have not been confirmed, and (e) common factors (CF) interventions are at least as powerful as ESTs but may significantly increase overall effect sizes. We agree with Laska and colleagues (2014) in suggesting that the data are overwhelming on these five points. But, we wish to add two substantial caveats to their conclusions: (a) their admonitions are not new and (b) they do not go far enough.
A Search for Integration Not Simply Amalgamation The idea of combining CFs and unique or distinctive contributors to change has been argued by numerous authors for more than
Larry E. Beutler, Pacific Graduate School of Psychology, Palo Alto University. Correspondence concerning this article should be addressed to Larry E. Beutler, 2620 Piedra Verde Court, Placerville, CA 95667. E-mail: [email protected] 496
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.
COMMON FACTORS—COMMENT
Electing not to be confined to the study of brand-named interventions and patient diagnoses as grist for the treatment-matching mill, and spurred by the work of Goldfried (1980), Prochaska (1979), and colleagues (Prochaska & DiClemente, 1982), in the mid-1980s, integrative investigators began to identify a set of principles or strategies that would identify and bring the effects of relationship, participant, and contributors to treatment–patient “fit” into a cohesive and cross-cutting perspective. These principles include but are not restricted to the inclusion of CFs as mediators of change; they also include the identification of cross-cutting moderators of change in an effort to fill out the picture of effective psychotherapy. With the concern that the CF perspective inaccurately equated “common factors” with “nonspecific” ones in producing change, integrationists began looking to cross-cutting dimensions that were differentially associated with specific change. For example, Beutler and Clarkin (1990) combined their early and overlapping technical eclectic efforts (Beutler, 1983; Frances, Clarkin, & Perry, 1984) into a more comprehensive system that incorporated the predictive power of patient (diagnostic and nondiagnostic) factors, settings and contexts, relationship qualities, and specific modes and formats of treatment as well as discrete classes of interventions. Beginning with a comprehensive review of the psychotherapy literature on specific effects, they derived a list of more than 40 variables that exerted a notably mediating and often differential or “moderating” effect on outcomes. These variables included relationship factors, therapist and patient factors, and contexts, drawing from CF, persuasion research, and RCT research. From this list, they proposed a system of cross-cutting treatment planning principles that fit specific patients to particular therapeutic styles and classes of intervention. Ten years later, these authors collaborated again (Beutler, Clarkin, & Bongar, 2000) to: (a) update their earlier literature review; (b) refine the list of predictors by reducing overlap and sharpening the criteria for inclusion; (c) develop measures of the relevant participant, contextual, and treatment variables that comprised predictors from their review of literature; and (d) conduct a crossvalidation study of the direct and moderating effects of the resulting groups of variables on outcomes among a large sample of mixed patients. Out of this effort, 18 principles that characterized optimally effective psychotherapy and psychotherapy fit were defined, consensually validated, and cross-validated. These principles reflected the actions of a broad array of both mediators and moderators of change. They included aspects of the relationship, aspects of patient risk and severity as well as coping style and resistance level, and therapist behaviors associated with personal style and selective interventions. Recognizing that the principles defined by one group may lack consensual validity for another, Castonguay and Beutler (2006) convened a task force sponsored jointly by the North American Society for Psychotherapy Research and Division 12 of the American Psychological Association. This task force was charged with independently reviewing extant psychotherapy literature with an eye toward constructing an independent list of cross-cutting principles on which comprehensive interventions could be built. A panel of 24 distinguished scholars, representing multiple theoretical perspectives, were selected, recruited, and assigned to work in contrasting pairs (assisted by 21 coauthors of their choice), to review the psychotherapy literature focusing on treatment of four
497
diagnostic groups (depression, anxiety, chemical abuse, and personality disorder) and within three domains of influence (participant factors, interventions, and relationships/contexts). They initially distilled the literature in their assigned area into a series of principles that they concluded were empirically established. A consensus meeting of authors reduced the list to 61 principles, 26 that were identified in more than one of the four problem areas (common principles) and 35 that had been identified in only one of the problem areas (unique principles). The nomenclature adopted by Castonguay and Beutler (2006) illustrates an important distinction between how the terms “common” and “specific” are used in an integrative context and how it is used in the CF literature. Table 1 illustrates this difference. This table provides a list of eight principles, extracted and somewhat reworded from the original Castonguay and Beutler list of 61. These eight principles are currently being used by my colleagues and me (Beutler et al. 2014) as the foundation for learning psychotherapy in a university clinic that trains PhD and PsyD students. Principles 2, 3, and 4, will probably be recognized by CF advocates as reflecting “common” factors. The other principles, however, are generally ignored by CF and RCT researchers. Nonetheless, from an integrated perspective, all the principles are “common” in that they apply equally to various theory-based models of psychotherapy. The difference is that to the integrationist, Principles 1, 5, 6, 7, and 8 address the role of moderators, and unlike the CF, “common factors” predict a patient by treatment differential effect on treatment outcome. Although CF and integrative advocates may differ in what they view as constituting “common” factors, as one articulates the essence of psychotherapy from these two perspectives, it quickly becomes clear that these two groups of researchers share a common interest in encouraging the use of a broad set of methodologies to uncover optimal fits of contexts, participants, and interventions. This perspective contrasts with those who define psychotherapy by the interventions alone and who, in so doing, view randomized clinical trials as a gold-standard methodology. This observation led Beutler (2009; Beutler & Forrester, 2014) and others (Norcross, 2011) to advocate a more inclusive research definition of psychotherapy than that advocated by EST researchers (Baker, McFall, & Shoham, 2008). These scholars advocate expanding the list of variables studied and the research methods accepted as evidence of “empirical support” to converge on the underlying interplay of effective psychotherapy processes. This recommendation has been accompanied by a series of demonstrations (Beutler, 2009; Beutler, Forrester, Gallagher-Thompson, Thompson, & Tomlins, 2012) that illustrate how classes of interventions (rather than therapy brands) combine with participant factors (e.g., patient personalities and therapist skill, therapist helpfulness, preferences, and interpersonal relationships) to evoke change. These participant factors often cannot be randomly assigned, but nonetheless have proven themselves in abundant research literature (Garfield, 1980; Norcross, 2011) to be variables that interact with interventions to produce change. This approach has confirmed the view that psychotherapy is more than a list of additive variables drawn from CF and RCT traditions, but is an interactive and complementary cluster of intersecting mediating and moderating variables that complement one another to enhance change (Beutler et al., 2003; Beutler et al., 2012).
BEUTLER
498
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.
Table 1 Principles of Therapeutic Change—An Example Impairment-level principle. 1. For all patients with moderate to severe impairment, the therapist should identify social service or medical care needs and arrange for attention to these needs. Those with low social support systems, in particular, need assistance from the therapist to develop social support and support services. This may mean the use of adjunctive group or multiperson interventions. Relationship principles. Three principles draw the supervisors’ and students’ attention to the importance of the therapeutic relationship in effecting change. 2. Therapy is likely to be beneficial if a strong working alliance is established and maintained during the course of treatment. 3. The qualities of a good working alliance are likely to be facilitated if the therapist relates to clients in an empathic way; adopts an attitude of caring, warmth, and acceptance; and adopts an attitude of congruence or authenticity. 4. Therapists are likely to resolve alliance ruptures when addressing such ruptures in an empathic and flexible way. Resistance principles. One principle describes the central role of varying one’s approach when client resistance is encountered. 5. In dealing with the resistant client, the therapist’s use of directive therapeutic interventions should be planned to inversely correspond with the patient’s manifest level of resistant traits and states. Nonconfrontational strategies are most helpful in working with such clients. Coping-style principles. Ways that clients cope with change affect the goals that optimally guide psychotherapy. Two principles define this relationship. 6. Clients whose personalities are characterized by relatively high “externalizing” styles (e.g., impulsivity, social gregariousness, emotional liability, and external blame for problems) benefit more from direct behavioral change and symptom reduction efforts, including building new skills and managing impulses, than they do from procedures that are designed to facilitate insight and self-awareness. 7. Clients whose personalities are characterized by relatively high “internalizing” styles (e.g., low levels of impulsivity, indecisiveness, selfinspection, and overcontrol) tend to benefit more from procedures that foster self-inspection, self-understanding, insight, interpersonal attachments, and self-esteem than they do from procedures that aim at directly altering symptoms and building new social skills. Readiness principle. Client readiness and receptivity are important qualities, but patients differ widely in these qualities. Stages of readiness that predict treatment effects have been identified. 8. Clients who are in more advanced stages of readiness for change (e.g., preparation, action, and maintenance) are more likely to improve in psychotherapy than those at lower stages of readiness (pre-contemplation and contemplation).
This integrative view is gaining ground among others who view contemporary EBP and EST research to be unnecessarily and inappropriately narrow. Recently, a group of 19 senior scholars (Holt et al., 2013), all whom are either past presidents of Divisions 29, 12, and 50 of the American Psychological Association, past presidents of the North American Society for Psychotherapy Research, or past presidents of the (international) Society for Psychotherapy Research, called on the Department of Veterans Affairs Health Care Systems to expand the criteria by which EBPs are identified in their system to include evidence drawn from methodological alternatives to RCT designs and that incorporates CF and integrative constructs into practice. Beutler and Forrester (2014) reinforced this view by outlining and illustrating a way to incorporate CF and integrationist research into most RCT designs to facilitate an understanding of the complexity of change. With these developments, the path is being paved for a future that could include agreements on multiple fronts among investigators and practitioners.
The Future of Integrative and CF Perspectives While not a soothsayer, I continue to believe that the future belongs to the broad, not the narrow, thinkers. An inclusive view will, in the end, give us the greatest ability to help others. Whether that view will fully integrate CF, integrationist, and RCT views or will be a more limited amalgamation such as that proposed by Laska et al. (2014) is not clear. We scientists are bound, as are all humans, to fight to maintain our beliefs intact, even if it means denying and rejecting even well-validated views of others, as long as we can find a smattering of evidence that will allow us to do so. But, there is one thing that we could collectively do, that would open the door to a science of psychotherapy more than any other. We could agree that the effects of psychotherapy have many
determinants and, therefore, are best studied via a multiplicity of rigorous methods. To advance, I believe that we must assume this broad view rather than adhering to an archaic “gold” standard that defines “science” solely through the lens of an RCT methodology. If the capacity to be randomly assigned is the only criterion that truly matters in determining what is and is not a science, neither astrophysics or climatology, nor for that matter classical physics or chemistry, would be considered “scientific.” We would still live in a heliocentric universe, walking on a flat earth, and denying human influences in climate change. Indeed, it is decidedly “unscientific,” in our view, to define science by one’s use of a single research methodology. Science thrives when it is multidimensional and is left behind if it does not develop methods of measuring and gathering evidence from multiple methods and perspectives. By opening the door to multiple methodologies and openly acknowledging that psychotherapy influence is not a simple matter of identifying and applying interventions, I believe the appeal of psychotherapy would be enhanced. I think those who are recipients of effective psychotherapy understand that the essence of its effects relies on the discriminant use of participant factors, both therapist and patient, as well as contextual factors, interventions, and authentic relationships, to achieve an optimal fit of factors that promote beneficial change. Making a decision simply to broaden our definition of acceptable methods would take us beyond the limitations imposed when we restrict our attention to diagnosis and therapist orientation. In short, if psychotherapy research groups would all accept the simple proposition that good science incorporates the strengths of multiple methods, it would encourage research to determine if an integration, as proposed here, or an amalgamation between treatment-specific interventions and CFs, as proposed by Laska et al. (2014), best fits the aims of improved prediction and control.
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.
COMMON FACTORS—COMMENT
The selective and progressive use of multiple methods allows one to partial the influence of contributors to change in ways that can increase the likelihood of beneficial gains substantially through treatment selection and application (Beutler & Forrester, 2014; Beutler, 2009; Beutler et al., 2003). Finally, such a shift of perspective would allow us to acknowledge what we already accept in practice, namely that psychotherapy involves a much larger array of activities and constructs than that which is defined by our techniques and brands of intervention. As a demonstration of where such a broad view of psychotherapy may lead, Constantino, Castonguay, and Beutler (2014) are currently refining the principles originally articulated by Castonguay and Beutler (2006), reducing overlap, confirming their status as common or specific predictors, and testing them against a standard criteria of empirical validity. In a final step, they are asking practicing therapists to help us identify how these principles would and could be used in their own practices. Although this is still a work in progress, three things are already clear: (a) the list of empirically supported principles of change will include representatives of participants, interventions, and contexts/relationships; (b) a relatively small number of principles can be articulated that will capture the variety that is psychotherapy; and (c) by far the preponderance of these principles describes effects that are “common” across brands of intervention and diagnostic groups. Although subject to change as our research progresses, about one-third of the empirically supported principles of change pertain to the use of differential interventions (i.e., moderators of change) and the rest reflect on participant and relationship factors that mediate change. Psychotherapy of the future may look at how principles of change interface with one another rather than being consolidated around horse races among different brands of intervention.
References Baker, T. B., McFall, R. M., & Shoham, V. (2008). Current status and future prospects of clinical psychology: Toward a scientifically principled approach to mental and behavioral health care. Psychological Science in the Public Interest, 9, 67–103. Beutler, L. E. (1983). Eclectic psychotherapy: A systematic approach. New York, NY: Pergamon Press. Beutler, L. E. (2009). Making science matter in clinical practice: Redefining psychotherapy. Clinical Psychology: Science and Practice, 16, 301– 317. doi:10.1111/j.1468-2850.2009.01168.x Beutler, L. E., & Clarkin, J. F. (1990). Systematic treatment selection: Toward targeted therapeutic interventions. New York, NY: Brunner/ Mazel. Beutler, L. E., Clarkin, J. F., & Bongar, B. (2000). Guidelines for the systematic treatment of the depressed patient. New York, NY: Oxford University Press. doi:10.1093/acprof:oso/9780195105308.001.0001 Beutler, L. E., & Forrester, B. (2014). What needs to change: Moving from “research informed” practice to “empirically effective” practice. Journal of Psychotherapy Integration, 24, 168 –177. doi:10.1037/a0037587 Beutler, L. E., Forrester, B., Gallagher-Thompson, D., Thompson, L., & Tomlins, J. B. (2012). Common, specific and treatment fit variables in psychotherapy outcome. Journal of Psychotherapy Integration, 22, 255– 281. doi:10.1037/a0029695 Beutler, L. E., Kimpara, S., Haug, N., Macias, S., Shiloff, N., & Goldblum, P. (2014). Enhancing Psychotherapy Training with the use of STS/ Innerlife Feedback in Supervision at the Gronowski Center. A research
499
program in progress. Unpublished manuscript, Palo Alto University, Palo Alto, CA. Beutler, L. E., Moleiro, C., Malik, M., Harwood, T. M., Romanelli, R., Gallagher-Thompson, D., & Thompson, L. (2003). A comparison of the Dodo, EST, and ATI indicators among co-morbid stimulant dependent, depressed patients. Clinical Psychology and Psychotherapy, 10, 69 – 85. doi:10.1002/cpp.354 Budd, R., & Hughes, I. (2009). The dodo bird verdict— controversial, inevitable and important: A commentary on 30 years of meta-analyses. Clinical Psychology and Psychotherapy, 16, 510 –522. doi:10.1002/cpp .648 Castonguay, L. G., & Beutler, L. E. (Eds.). (2006). Principles of therapeutic change that work: Integrating relationship, treatment, client, and therapist factors (Vol. I). New York, NY: Oxford University Press. Chambless, D. L., & Hollon, S. D. (1998). Defining empirically supported therapies. Journal of Consulting and Clinical Psychology, 66, 7–18. doi:10.1037/0022-006X.66.1.7 Constantino, M., Castonguay, L. G., & Beutler, L. E. (Eds.). (2014). Principles of psychotherapy that work: Applications (Vol. II). Manuscript in preparation. New York, NY: Oxford University Press. Frances, A., Clarkin, J., & Perry, S. (1984). Differential therapeutics in psychiatry. New York, NY: Brunner/Mazel. Garfield, S. L. (1980). Psychotherapy: An eclectic approach. New York, NY: Wiley. Goldfried, M. R. (1980). Toward the delineation of therapeutic change principles. American Psychologist, 35, 991–999. doi:10.1037/0003066X.35.11.991 Holt, H., Beutler, L. E., Castonguay, L. G., Silberschatz, G., Forrester, B., Temkin, R., . . . Miller, T. W. (2013). A critical examination of the movement toward evidence-based treatments in the U.S. Department of Veterans Affairs. The Clinical Psychologist, 66, 8 –12. Laska, K. M., Gurman, A. S., & Wampold, B. E. (2014). Expanding the lens of evidence-based practice in psychotherapy: A common factors perspective. Psychotherapy, 51, 467– 481. doi:10.1037/a0034332 Lazarus, A. A. (1967). In support of technical eclecticism. Psychological Reports, 21, 415– 416. Norcross, J. C. (Ed.). (2011). Psychotherapy relationships that work: Therapist contributions and responsiveness to patient needs (2nd ed.). New York, NY: Oxford University Press. doi:10.1093/acprof:oso/ 9780199737208.001.0001 Norcross, J. C., & Lambert, M. J. (2006). The therapy relationship. In J. C. Norcross, L. E. Beutler, & R. F. Levant (Eds.), Evidence-based practices in mental health: Debate and dialogue on the fundamental questions (pp. 208 –218). Washington, DC: American Psychological Association. doi: 10.1037/11265-000 Prochaska, J. O. (1979). Systems of psychotherapy: A transtheoretical analysis. Homewood, IL: Dorsey. Prochaska, J. O., & DiClemente, C. C. (1982). Transtheoretical therapy: Toward a more integrative model of change. Psychotherapy: Theory, Research, and Practice, 19, 276 –288. doi:10.1037/h0088437 Wampold, B. E. (2001). The great psychotherapy debate: Models, methods, and findings. Mahwah, NJ: Erlbaum. Wampold, B. E., & Budge, S. L. (2012). The 2011 Leona Tyler Award address: The relationship–and its relationship to the common and specific factors of psychotherapy. The Counseling Psychologist, 40, 601– 623. doi:10.1177/0011000011432709 Wampold, B. E., Mondin, G. W., Moody, M., Stich, F., Benson, K., & Ahn, H. (1997). A meta-analysis of outcome studies comparing bona fide psychotherapies: Empirically, “All must have prizes”. Psychological Bulletin, 122, 203–215. doi:10.1037/0033-2909.122.3.203
Received February 3, 2014 Accepted February 4, 2014 䡲
