Lecture 1 – Common factors
What makes a common factor “common”?
Although treatment methods differ in their approach, the general belief is that there are also
measurable, yet not so perceivable mechanisms at work that contribute towards change in
people.
They are common mechanisms in most people and it is expected to be part of our socio-
biological heritage. Therefore, in psychotherapy we have patient factors and therapist factors.
The verdict is unclear what percentage of common factors contributes towards effectiveness
of therapy
o But what we do know is that specific treatment methods rarely surpass 50% response
rate to a certain treatment.
Why are differences important?
It helps to understand why different therapy models are more or less similarly effective and
that all methods probably have blind spots.
But also:
o It is alright to have a preference for different models as a therapist (as do patients)
o It stimulates us to think about universal working models for the human psyche
o It provides a universal language to communicate about phenomenon across
psychotherapy methods.
The contextual model for common factors
The real or therapeutic relationship
The therapeutic relationship or alliance starts with the first impression; like all social encounters
Defining a relationship
o Different roles each plays (patient and therapist)
o Trustworthiness (safety and confidentiality)
o Reliability (will you be there for me?)
o Verbal and non-verbal communication
o Level of cooperation towards forming “a working alliance”
o Empathy or closeness and “warmth”
o Holding: the capacity of the therapist to manage all these factors and maintaining a
secure therapeutic relationship
o Healing relationship
People have social needs
Social interaction can be healing trough
Understanding
Mentalization
Perspective taking
Empathy
Sense of togetherness
Attachment
o Especially an important factor in persisting psychopathology
like PDs
o But not exclusively, more and more evidence available of
attachment as a predictor for other psychopathology
o Furthermore, attachment predicts treatment outcome.
Managing emotions and anxiety
The role of attachment
, Transference
o = the interaction between an patient and a therapist and is complicated.
o Factors influencing the transference:
Patient
Past
Present
How are you doing? – mood
Past (failed) therapy
Problems at home
o Not exclusively for the patient
o The therapist is also not only a therapist for himself
He or she might be a parent
Might have a bad day
Might have trauma in their own past
Might have feelings towards a patient
o The therapeutic relationship is constantly in danger because of complicating but
normal social phenomenon. To complicate things even further, you can be aware of
these or you might as well not be aware.
o Transference is a product formed by the factors that are brought into the therapeutic
relation by both patient and therapist
o Managing transference
Common method for managing transference is using
Leary’s rose
Although elegant and simple, often this method on its
own is insufficient! Different treatment methods have
additional techniques.
Furthermore: intervision and supervision are important
in recognizing therapist transference and own
limitations
Boundaries
o Clear boundaries are necessary in every treatment in every
method. They identify what the relationship should look like and helps the therapist
identify when there is a healthy working alliance, or when trouble arises.
o It also provides clarity, and with clarity security and safety for the patient.
o Furthermore, it provides an opportunity to talk about transference.
Expectations and how to manage them
Once again both therapist and the patient will bring expectations to therapy
Important factors are
o Timing
o Previous experiences
o Beliefs about the complaints of the patient
o Beliefs about the solutions for the complaints problems which most of the time lead
to demoralization motivational problems
How do we alter expectations?
o Providing the patient a working model with a therapy method or conceptualization of
the problem
From a rigid to an adaptive explanation model
o Psycho-education about their problem and the treatment
Remoralization and establishing hope
, o Promoting self-efficacy, sense of control, sense of mastery and autonomy. Improving
the sense of self-esteem and capacity to change their behavior and situation.
o Discussing and changing response expectancies
o Therapist and patient should be in agreement about the above describes factors
before continuation (and should be discusses over and over if needed)
Consider it a contract for the treatment
Treatment outcome and attachment
Secure attachment
o Easy forming of treatment alliance
o Should go pretty much straight forward
Anxious-preoccupied attachment
o Easy forming of treatment alliance
o Difficulties in terminating treatment
o Therapist needs to have abundant patience
Fearful-avoidant attachment
o Forming of secure alliance takes time
o Might seem less motivated, but this is not the case
o At risk of rejection by the therapist
o More focused on skill and problem-solving. Less on the relationship
Disorganized attachment
o Therapist needs to have abundant patience
Attachment and epistemic trust
Epistemic trust = capacity to learn trough a relationship and attachment.
o Insecure attachment styles interfere the presence of epistemic trust.
Managing stress
Specific ingredients
Although the common factors discussed before are important, on their own they have been
proven to be insufficient on their own. So the choice and fit of the treatment method also
have a major effect on the treatment outcome.
What makes a common factor “common”?
Although treatment methods differ in their approach, the general belief is that there are also
measurable, yet not so perceivable mechanisms at work that contribute towards change in
people.
They are common mechanisms in most people and it is expected to be part of our socio-
biological heritage. Therefore, in psychotherapy we have patient factors and therapist factors.
The verdict is unclear what percentage of common factors contributes towards effectiveness
of therapy
o But what we do know is that specific treatment methods rarely surpass 50% response
rate to a certain treatment.
Why are differences important?
It helps to understand why different therapy models are more or less similarly effective and
that all methods probably have blind spots.
But also:
o It is alright to have a preference for different models as a therapist (as do patients)
o It stimulates us to think about universal working models for the human psyche
o It provides a universal language to communicate about phenomenon across
psychotherapy methods.
The contextual model for common factors
The real or therapeutic relationship
The therapeutic relationship or alliance starts with the first impression; like all social encounters
Defining a relationship
o Different roles each plays (patient and therapist)
o Trustworthiness (safety and confidentiality)
o Reliability (will you be there for me?)
o Verbal and non-verbal communication
o Level of cooperation towards forming “a working alliance”
o Empathy or closeness and “warmth”
o Holding: the capacity of the therapist to manage all these factors and maintaining a
secure therapeutic relationship
o Healing relationship
People have social needs
Social interaction can be healing trough
Understanding
Mentalization
Perspective taking
Empathy
Sense of togetherness
Attachment
o Especially an important factor in persisting psychopathology
like PDs
o But not exclusively, more and more evidence available of
attachment as a predictor for other psychopathology
o Furthermore, attachment predicts treatment outcome.
Managing emotions and anxiety
The role of attachment
, Transference
o = the interaction between an patient and a therapist and is complicated.
o Factors influencing the transference:
Patient
Past
Present
How are you doing? – mood
Past (failed) therapy
Problems at home
o Not exclusively for the patient
o The therapist is also not only a therapist for himself
He or she might be a parent
Might have a bad day
Might have trauma in their own past
Might have feelings towards a patient
o The therapeutic relationship is constantly in danger because of complicating but
normal social phenomenon. To complicate things even further, you can be aware of
these or you might as well not be aware.
o Transference is a product formed by the factors that are brought into the therapeutic
relation by both patient and therapist
o Managing transference
Common method for managing transference is using
Leary’s rose
Although elegant and simple, often this method on its
own is insufficient! Different treatment methods have
additional techniques.
Furthermore: intervision and supervision are important
in recognizing therapist transference and own
limitations
Boundaries
o Clear boundaries are necessary in every treatment in every
method. They identify what the relationship should look like and helps the therapist
identify when there is a healthy working alliance, or when trouble arises.
o It also provides clarity, and with clarity security and safety for the patient.
o Furthermore, it provides an opportunity to talk about transference.
Expectations and how to manage them
Once again both therapist and the patient will bring expectations to therapy
Important factors are
o Timing
o Previous experiences
o Beliefs about the complaints of the patient
o Beliefs about the solutions for the complaints problems which most of the time lead
to demoralization motivational problems
How do we alter expectations?
o Providing the patient a working model with a therapy method or conceptualization of
the problem
From a rigid to an adaptive explanation model
o Psycho-education about their problem and the treatment
Remoralization and establishing hope
, o Promoting self-efficacy, sense of control, sense of mastery and autonomy. Improving
the sense of self-esteem and capacity to change their behavior and situation.
o Discussing and changing response expectancies
o Therapist and patient should be in agreement about the above describes factors
before continuation (and should be discusses over and over if needed)
Consider it a contract for the treatment
Treatment outcome and attachment
Secure attachment
o Easy forming of treatment alliance
o Should go pretty much straight forward
Anxious-preoccupied attachment
o Easy forming of treatment alliance
o Difficulties in terminating treatment
o Therapist needs to have abundant patience
Fearful-avoidant attachment
o Forming of secure alliance takes time
o Might seem less motivated, but this is not the case
o At risk of rejection by the therapist
o More focused on skill and problem-solving. Less on the relationship
Disorganized attachment
o Therapist needs to have abundant patience
Attachment and epistemic trust
Epistemic trust = capacity to learn trough a relationship and attachment.
o Insecure attachment styles interfere the presence of epistemic trust.
Managing stress
Specific ingredients
Although the common factors discussed before are important, on their own they have been
proven to be insufficient on their own. So the choice and fit of the treatment method also
have a major effect on the treatment outcome.
