Are All Psychological Therapies Equally Effective? 

Rosenzweig (1936) noted that diverse psychotherapies often prove similarly successful, leading him to question what common factors make them equally effective.

He referenced the Dodo bird’s quote from Alice’s Adventures in Wonderland, “Everybody has won, and all must have prizes,” and his assertion that different therapies have equivalent outcomes became known as the Dodo bird verdict.

This idea has been empirically supported by research finding few differences between legitimate treatments (e.g., Luborsky et al., 2002; Wampold & Imel, 2015).

Rosenzweig (1936) argued for the importance of common factors in psychotherapy without specifying what they were, only mentioning social reconditioning and catharsis as examples.

However, the debate between common factors and specific factors continues.

While some argue that common factors, such as therapeutic alliance, empathy, and positive regard, are the primary drivers of therapeutic change (Norcross & Lambert, 2019), others emphasize the importance of specific factors, such as particular interventions or techniques.

The complex interplay between common and specific factors, as well as therapist effects and patient characteristics, likely contributes to the effectiveness of psychological therapies.

Specific Factors

Specific factors in psychotherapy refer to the unique, theory-driven elements, interventions, or techniques that are believed to be the active ingredients responsible for therapeutic change within a particular treatment approach (Wampold & Imel, 2015).

These factors are often outlined in treatment manuals and are considered distinct from common factors, which are shared across different therapies.

Examples of specific factors include:

1. Cognitive restructuring: A key technique in cognitive therapy that involves identifying and challenging maladaptive thoughts and beliefs.
2. Exposure therapy: A central component of many cognitive-behavioral treatments for anxiety disorders, which involves gradually exposing patients to feared stimuli or situations.
3. Transference interpretation: A psychodynamic intervention that involves highlighting and exploring the patient’s unconscious reactions to the therapist that stem from past relationships.
4. Mindfulness meditation: A core practice in mindfulness-based therapies that involves cultivating present-moment awareness and acceptance.

Proponents of specific factors argue that these unique elements are crucial for therapeutic effectiveness and that different psychological disorders require different treatment approaches (Siev, Huppert, & Chambless, 2009).

However, the relative contribution of specific factors compared to common factors in therapeutic change remains a topic of ongoing debate and research in the field of psychotherapy (Laska, Gurman, & Wampold, 2014).

Common Factors

Frank’s common factors model focused on four therapeutic components (Frank, 1961; see also Frank & Frank, 1993):

1. An emotionally charged, confiding relationship with a helping person.
2. A healing setting, which provides safety and increases the patient’s expectations of being helped by strengthening the therapist’s status as a healer.
3. A rationale or myth that explains the patient’s distress.
4. A healing ritual that requires the endorsement and active participation of both patient and therapist.

Wampold and Imel (2015) proposed a contextual model of psychotherapy that includes three pathways:

1. A real relationship based on genuineness and realistic perceptions (Gelso, 2009), which provides some therapeutic benefit in and of itself.
2. Expectations of improvement, which are fostered through credible, adaptive explanations for the patient’s difficulties and therapeutic actions consistent with those explanations.
3. Specific ingredients that encourage patients to engage in health-promoting behaviors or cease engaging in harmful behaviors.

Like Frank’s model, the emphasis is not on prescribing specific ingredients; what matters is that they are coherent with the treatment’s explanations and rituals and encourage healthy behaviors.

Grencavage and Norcross (1990) conducted a literature review that identified 89 common factors, grouped into five categories: patient characteristics, therapist qualities, change processes, treatment structure, and relationship elements.

1. Common Patient Characteristics

1. Interpersonal problems: Difficulties or challenges individuals experience in their relationships. These problems can be organized along two dimensions: agency/dominance (“getting ahead”) and communion/affiliation (“getting along”) (Horowitz, 2004).
   
   Interpersonal problems are often connected to psychological disorders and are a significant target for change in psychotherapy.
2. Treatment outcome expectation: Patients’ prognostic beliefs about the consequences of engaging in psychotherapy (Constantino et al., 2019). In other words, it is the patient’s expectation of how effective or beneficial the treatment will be in addressing their concerns or problems.
3. Stages of change: The transtheoretical model posits five stages of change (Prochaska & DiClemente, 1983). A meta-analysis found a moderate-sized relation between patients’ readiness to change at pretreatment and their therapy outcomes (Krebs et al., 2019).
   
   Only about 20% of patients enter therapy in the action stage (patients actively engage in making changes to their behavior), with about 40% in the pre-contemplation stage (don’t recognize a problem) and 40% in the contemplation stage, where patients acknowledge the problem but are not yet ready to take action (Norcross et al., 2011).

2. Common Therapist Qualities

Therapist-related factors refer to therapists’ characteristics, actions, and interpersonal variables associated with patient-level outcomes, regardless of the specific therapeutic approach used.

These factors are typically examined through correlational analyses between therapist variables and patient outcomes.

1. Empathy: Therapists’ ability to understand the patient’s frame of reference and way of experiencing the world (Rogers, 1957). A meta-analysis found empathy to be a moderately strong predictor of treatment outcome (Elliott et al., 2019).
2. Positive regard: The therapist’s warm acceptance of the patient, which serves to strengthen the patient’s sense of self, reinforce engagement in therapy, and facilitate growth (Farber et al., 2019). A meta-analysis found a small but significant positive association between positive regard and treatment outcome (Farber et al., 2019).
3. Genuineness: The therapist’s ability to be authentic and communicate this authenticity to the patient. Rogers (1957, p. 97) defined genuineness, or congruence, as the therapist’s ability to be “freely and deeply himself” and to communicate this authenticity to the patient. A meta-analysis found a small to medium association between therapist genuineness and positive patient outcomes (Kolden et al., 2019).
4. Appropriate responsiveness: The therapist’s ability to flexibly tailor treatment to the patient’s needs in the moment (Stiles et al., 1998). Research demonstrates that adapting psychotherapy to the individual patient can be effective and may explain why therapy works (Norcross & Wampold, 2019; Stiles & Horvath, 2017).

Therapist effects (therapist differences in effectiveness) account for 3-8% of outcome variance. Variables differentiating better-performing therapists include greater facilitative interpersonal skills, professional self-doubt, and deliberate practice.

3. Common Change Processes

Common change processes are therapeutic factors believed to facilitate positive outcomes across different therapy approaches.

Goldfried’s common principles (Eubanks & Goldfried, 2019; Goldfried, 1980):

1. Fostering the patient’s hope, positive expectations, and motivation
2. Facilitating the therapeutic alliance: e.g., therapeutic alliance, instillation of hope, readiness to change, resource activation
3. Increasing the patient’s awareness and insight: e.g., awareness of connections between thoughts, feelings, needs, actions
4. Encouraging corrective experiences: i.e., encouraging patients to take risks and engage in new behaviors that lead to a shift in cognitions and emotions)
5. Emphasizing ongoing reality testing: i.e., helping patients to process corrective experiences and consolidate positive changes by recalibrating their expectations and self-views to be in line with their new reality)

Bernese general change factors (Caspar & Holtforth, 2010; Grawe, 1995, 2004):

1. Mastery/coping: The patient learns to cope with difficult or anxiety-provoking situations.
2. Clarification of meaning: The patient gains greater understanding of the source of their difficulties.
3. Problem actuation: The patient’s emotional experience of the problem is activated during psychotherapy, to provide the optimal opportunity to foster change.
4. Resource activation: The patient’s own resources—motivation, skills, strengths—are activated in the service of change.

The Taxonomy Project (Pfammatter & Tschacher, 2016; Tschacher et al., 2014):

1. Cognitive processing: Includes provision of explanatory scheme, insight, mentalization, and cognitive restructuring.
2. Problem-solving: Includes desensitization, behavior regulation, and mastery experiences.
3. Emotional affective experiencing: Includes affective catharsis, corrective emotional experience, and mindfulness.
4. Building the therapeutic alliance and patient motivation: Includes therapeutic alliance, instillation of hope, readiness to change, and resource activation.

Evidence-based principles of change (Castonguay & Beutler, 2006; Castonguay et al., 2019):

1. Patient prognostic principles: Patient characteristics that predict treatment outcome, such as baseline impairment, personality disorder, attachment, expectations, and stage of change.
2. Treatment/provider moderating principles: Patient characteristics, often present at baseline, that therapists should be responsive to, such as patient resistance, ambivalence, and coping style.
3. Patient process principles: Patient during-treatment behaviors that facilitate or interfere with improvement, such as active participation or resistance, respectively.
4. Therapy relationship principles: Elements of the patient–therapist exchange that facilitate improvement, such as alliance quality, alliance rupture repair, therapist empathy, and therapist positive regard.
5. Therapist intervention principles: Therapist during-treatment behaviors that facilitate improvement, such as receiving feedback based on routine outcome monitoring, being flexible, and fostering more emotional experiencing and behavior change.

4. Treatment Structure

Treatment structures, such as the virtual healing setting, have received less attention in the psychotherapy literature than other common factors (Grencavage & Norcross, 1990).

However, the COVID-19 pandemic forced many therapists to switch to online therapy, leading to concerns about technical issues and the patient-therapist interaction (Aafjes-van Doorn et al., 2021).

Therapists reported feeling less connected to patients, having difficulty reading emotions, and expressing empathy in online settings.

Although therapists initially felt online therapy was less effective, their views became more positive with experience, highlighting the need for training and research on facilitating relationship factors in internet interventions (Berger, 2017).

5. Relationship Elements

An expert panel reviewed meta-analyses and found strong research support for several relationship elements, including alliance, goal consensus, cohesion in group therapy, therapist empathy, and positive regard (Norcross & Lambert, 2019).

The Alliance

The therapeutic alliance is the collaborative and affective bond between therapist and patient. It encompasses agreement on the goals and tasks of therapy and the quality of the emotional bond (Bordin, 1979).

The alliance is considered one of the most important common factors in psychotherapy, and its significance is supported by extensive research evidence.

Several meta-analyses have consistently found that the alliance is a robust predictor of treatment outcomes across various therapeutic approaches and settings, including individual therapy with adults, child/adolescent therapy, and couples and family therapy (Flückiger et al., 2018; Friedlander et al., 2019; Karver et al., 2019).

The alliance remains a significant predictor even when controlling for patients’ intake characteristics and therapists’ adherence and competence (Flückiger, Del Re et al., 2020).

Moreover, research suggests a reciprocal relationship between the alliance and symptom reduction. Improvements in patient-rated alliance quality are associated with subsequent symptom reduction early in therapy, and symptom reduction, in turn, is associated with further improvement in the alliance (Flückiger, Rubel et al., 2020).

The importance of the alliance is further highlighted by research on alliance ruptures and repairs. Alliance ruptures, or tensions and breakdowns in the collaborative relationship between patient and therapist, are common in therapy.

However, evidence suggests that successful rupture repair is a common process that predicts positive treatment outcomes (Eubanks et al., 2019).

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