Common factors versus specific ingredients in therapy: Who wins?

One of the Big Issues in psychotherapy is, and has been for ages, whether the common factors (empathy, trust, the therapeutic relationship) or specific ingredients (the techniques) are more important to helping clients get better. This argument rages on, especially in training programs. We have limited time with our students to prepare them to go out into the world and make it all better for everyone (which is not much of an exaggeration in how most of us see our mission). So, how best to spend our precious semester hours: focusing teaching on the common factors or the specific ingredients?

If research funding is any sort of barometer of importance (and I’m not sure it is), you’d have to conclude that specific ingredients are where it’s at- sorry, I am pathologically incapable of ending a sentence with “at”, so here’s a useless clause. Almost all of the funding coming out of the big federal programs at NIMH, SAMHSA, and NIH are targeted at finding out what, specifically, works for all sorts of people and their problems. Some of the big pushes are aimed at developing multi-modal programs, where, for example, you might have medication management alongside psychotherapy and job skills training for addicts. The programs aimed at research on therapy itself, however, tend to focus on the specific: determining if cognitive-behavioral therapy works for people with eating disorders, finding new diagnostic indicators for PTSD, deciding how long a person with depression needs to be in cognitive-behavioral therapy to get back to work, etc. All of the big federal agencies fund big studies with the hope of finding big answers to big questions, and their work is extremely important.

The findings from the studies funded by the big agencies, and private entities, often drive what insurance companies and Medicaid/Medicare will reimburse providers for providing. The idea, called “evidence-based practice” sounds like solid common sense: they’ll only pay you to do things that research tells us actually works. It’s supposed, I guess, to keep therapists from waving feathers around and chanting and getting Blue Cross to pay for it. I’m all for effective treatment, as long as that’s really what we’re looking for in the research.

Here’s the rub: all of the big studies funded by the big agencies with big grants, which are the bases for the guidelines for reimbursement, look at the small picture- the specific ingredients. And guess what? We’ve known for at least two decades now that the specific ingredients aren’t as important as the common factors in treating clients effectively.

There were a couple of Very Important meta-studies in the 1990’s (Wampold comes to mind) that pretty clearly showed that it matters a lot less what you do in therapy than it does how you do it. Of course, because all endeavors must have critics, the idea that how trumps what has its detractors. Most often, they claim that common factors, which are squishy feelings, can’t be said to be more important than “medical” interventions, like behavior charting and thought stopping techniques. The medical-model side of the house, which often controls the federal funding apparatus, seem to think it unthinkable that the major mover in therapy is the relationship.

I imagine there are a couple of reasons that common factors theory isn’t taken as seriously as it might be. One reason is the squishy-feelings aspect of the common factors themselves. How do you “empirically” measure such things as empathy, insight, clinical judgment, and connection (I have empirically in quotes because I don’t believe true empiricism is possible in therapy research, but that’s a blog for another day)? It’s far more simple to measure how depressed or anxious a person getting Treatment A is than his neighbor in Treatment B than to devise a way to measure how Therapist A connects or doesn’t with Client B versus Client C. The second, more insidious, and I imagine, honest, reason for the continuing popularity of specific ingredients theory is the basic struggle between the chalice and the blade, or the feminine side of healing being rejected by the more masculine side.

It’s not a popular (or possibly, wise) thing to do to say that our whole Western medical model, especially in psychotherapy, may be predicated on the repression of the feminine. It’s also not really where I was planning to go with this essay when I started writing it, but I think at this point, leaving aside the obvious conflict between empiricism and feminism would be cowardly of me.

I don’t have any solution for the common factors vs. specific ingredients divide, but I think it bears more investigation, and probably with a bit of irony and a slightly jaundiced eye.

As for where I’m leaving off in regards to how to focus time with students of psychotherapy, I leave that to the recently departed genius Miller Williams, an excerpt from the magnificent poem, “The Associate Professor Delivers an Exhortation to his Failing Student”.

If one Sunday morning they should ask you

the only thing that matters after all,

tell them the only thing you know is true.

Tell them that failing is an act of love,

because like sin,

it is the commonality within.

How failing together we shall finally pass.

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