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Specific, Common, and Unintended Factors in Psychotherapy

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Specific, Common, and Unintended Factors in Psychotherapy University of Pennsylvania ScholarlyCommons Publicly Accessible Penn Dissertations Fall 2009 Specific, Common, and Unintended actF ors in Psychotherapy: Descriptive and Correlational Approaches to What Creates Change Kevin S. McCarthy University of Pennsylvania, [email protected] Follow this and additional works at: https://repository.upenn.edu/edissertations Part of the Clinical Psychology Commons Recommended Citation McCarthy, Kevin S., "Specific, Common, and Unintended actF ors in Psychotherapy: Descriptive and Correlational Approaches to What Creates Change" (2009). Publicly Accessible Penn Dissertations. 62. https://repository.upenn.edu/edissertations/62 This paper is posted at ScholarlyCommons. https://repository.upenn.edu/edissertations/62 For more information, please contact [email protected]. Specific, Common, and Unintended actF ors in Psychotherapy: Descriptive and Correlational Approaches to What Creates Change Abstract From the psychotherapy outcome literature, many have inferred that either theory-specific techniques or interventions common to all therapies are what produce symptom change. However, such conclusions are premature because (a) too few direct tests have been conducted of how variation in the levels of either specific or common factor interventions relate to outcome, (b) those prior investigations of specific and common factors and outcome have often been limited to examining linear relations between intervention use and outcome when curvilinear functions might better model their association, and (c) most studies of psychotherapy and outcome have failed to consider how interventions specific to theoretical orientations other than that being studied (i.e., interventions not intended to be in the specific treatment under investigation nor common to all therapies) might also contribute to outcome. In this thesis, I present two studies investigating the relation of interventions from a number of different therapy systems to subsequent symptom improvement in behavioral therapy for Obsessive-Compulsive Disorder (OCD) and psychodynamic therapy for Major Depressive Disorder (MDD). Theory-specific techniques were prominent in both therapies (e.g., behavioral techniques in behavioral therapy, psychodynamic techniques in dynamic therapy), and moderate levels of specific factors were related to better outcome than were higher or lower levels in each treatment. Common factor techniques were among the highest reported interventions in both treatments, but were not predictive of symptom improvement in either therapy. Interventions from other theoretical orientations were present in both therapies, but in such a way that individual techniques appeared to be selected for use based on their congruence with the theoretical orientation of the treatment. In behavioral therapy, no other types of interventions contributed to outcome more than behavioral interventions. In psychodynamic therapy, moderate levels of process-experiential techniques were associated with better outcome than were higher or lower levels. Further research needs to document how specific, common, and unintended factors occur in different psychotherapies and how such interventions might relate to outcome in complex ways before conclusions can be made about the mechanisms of therapy. Degree Type Dissertation Degree Name Doctor of Philosophy (PhD) Graduate Group Psychology First Advisor Jacques P. Barber Keywords interventions, adherence, psychotherapy, behavior therapy, alliance, curvilinear relations Subject Categories Clinical Psychology This dissertation is available at ScholarlyCommons: https://repository.upenn.edu/edissertations/62 SPECIFIC, COMMON, AND UNINTENDED FACTORS IN PSYCHOTHERAPY: DESCRIPTIVE AND CORRELATIONAL APPROACHES TO WHAT CREATES CHANGE Kevin S. McCarthy A DISSERTATION in Psychology Presented to the Faculties of the University of Pennsylvania in Partial Fulfillment of the Requirements for the Degree of Doctor of Philosophy 2009 Supervisor Jacques P. Barber, Ph.D., Professor of Psychology in Psychiatry Graduate Group Chairperson Michael J. Kahana, Ph.D., Professor of Psychology Dissertation Committee Dianne L. Chambless, Ph.D., Professor of Psychology Robert J. DeRubeis, Ph.D., Professor of Psychology SPECIFIC, COMMON, AND UNINTENDED FACTORS ii Acknowledgements I gratefully acknowledge Edna B. Foa and Elna Yadin for their support for the first study of this dissertation and the faculty and staff at the Center for the Treatment and Study of Anxiety (Shawn Cahill, Sandra Capaldi, Seth Gillihan, Elyssa Kushner, Jason Moser, Miles Lawrence, Tracey Lichtner, Monnica Williams, Elna Yadin, David Yusko) for their therapeutic expertise and their participation in data collection. I also would like to recognize the time and efforts of Smadar Barber, Taylor DiGravina, Lester Fogelsanger, and Jared Israel in coding session material for the second study in this dissertation. The assistance I received throughout my graduate career from Michael Greer, Gus Hartman, Claire Ingulli, Marie Poplas, and Pat Spann is of an incalculable value. Their ability to accomplish miracles within the University of Pennsylvania was amazing, and the hundreds of instances of kindness that they showed me have allowed this dissertation to come to completion. My advisory committee members have taught me so much through conversation, instruction, and their personal examples. Perhaps what I value most about my experience with them is how each has touched my life. By virtue of her diligence, Dianne Chambless literally oversaw every aspect of my graduate career, and probably many more elements of which I am not aware. I wish to be as patient and dedicated toward my own future students as she was toward me. Robert DeRubeis was the first to believe in me at the University of Pennsylvania, rescuing my graduate school application from the discard SPECIFIC, COMMON, AND UNINTENDED FACTORS iii pile when my undergraduate transcript was in error. He has a reputation for supporting and standing up for his students, and he has certainly earned that status in my eyes. Jacques Barber has truly been an advisor, teacher, and friend to me. How I have grown through his mentorship has been unquantifiable. At every step in the process, he has sought to challenge and expand my thinking, has encouraged me to develop and express my own ideas, and has pushed me whenever I showed a complacency or fixity. This description of Jacques’ mentoring applies not just to what he has done for my understanding of psychology and psychotherapy, but also for how I understand and feel about myself as a person and an academic. I hope that when he reads this it is not the first time I have made him aware of what he has meant to me and how grateful I am to have had him as a part of my life. SPECIFIC, COMMON, AND UNINTENDED FACTORS iv ABSTRACT SPECIFIC, COMMON, AND UNINTENDED FACTORS IN PSYCHOTHERAPY: DESCRIPTIVE AND CORRELATIONAL APPROACHES TO WHAT CREATES CHANGE Kevin S. McCarthy Jacques P. Barber From the psychotherapy outcome literature, many have inferred that either theory- specific techniques or interventions common to all therapies are what produce symptom change. However, such conclusions are premature because (a) too few direct tests have been conducted of how variation in the levels of either specific or common factor interventions relate to outcome, (b) those prior investigations of specific and common factors and outcome have often been limited to examining linear relations between intervention use and outcome when curvilinear functions might better model their association, and (c) most studies of psychotherapy and outcome have failed to consider how interventions specific to theoretical orientations other than that being studied (i.e., interventions not intended to be in the specific treatment under investigation nor common to all therapies) might also contribute to outcome. In this thesis, I present two studies investigating the relation of interventions from a number of different therapy systems to subsequent symptom improvement in behavioral therapy for Obsessive-Compulsive Disorder (OCD) and psychodynamic therapy for Major Depressive Disorder (MDD). Theory-specific techniques were prominent in both therapies (e.g., behavioral techniques in behavioral therapy, psychodynamic techniques in dynamic therapy), and moderate SPECIFIC, COMMON, AND UNINTENDED FACTORS v levels of specific factors were related to better outcome than were higher or lower levels in each treatment. Common factor techniques were among the highest reported interventions in both treatments, but were not predictive of symptom improvement in either therapy. Interventions from other theoretical orientations were present in both therapies, but in such a way that individual techniques appeared to be selected for use based on their congruence with the theoretical orientation of the treatment. In behavioral therapy, no other types of interventions contributed to outcome more than behavioral interventions. In psychodynamic therapy, moderate levels of process-experiential techniques were associated with better outcome than were higher or lower levels. Further research needs to document how specific, common, and unintended factors occur in different psychotherapies and how such interventions might relate to outcome in complex ways before conclusions can be made about the mechanisms of therapy. SPECIFIC, COMMON, AND UNINTENDED FACTORS vi Table of Contents Introduction 1 Specific Factors Hypothesis 3 Common Factors Hypothesis
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