Review Article Common Factors Affecting Psychotherapy Outcomes: ROBERT FEINSTEIN, MD NOA HEIMAN, PhD Some Implications for Teaching Psychotherapy JOEL YAGER, MD The number of psychotherapies classified as “has been defined in manuals and found efficacious “empirically supported treatments” has in at least 2 controlled clinical trials with random increased significantly. As the number and assignment, that include a control condition of scope of empirically supported treatments psychotherapy, placebo, pill, or other treatment and multiply, it has become impossible to train samples of sufficient power with well-characterized therapists in all of these specific modalities. patients.”3 Although these standards and the EST Although the current Accreditation Council literature are significant, from a psychotherapy for Graduate Medical Education requirements training perspective, the list of therapies meeting for psychiatric residents follow an approach this gold-standard has grown so rapidly that based on specific schools of psychotherapy attempting to teach the numerous forms of ESTs is (emphasizing competency in cognitive-behav- now impractical, if not impossible. Interested ioral therapy, psychodynamic therapy, and readers may wish to peruse http://www.apa.org/ supportive treatments), evidence suggests about/policy/resolution-psychotherapy.aspx for an that we are failing even in these efforts. In up-to-date list of psychotherapies considered by this developing a specialized Psychotherapy group, their assessments of the degree of supporting Scholars Track in the residency program at evidence, and the extent of controversy associated the University of Colorado School of Medicine, with each therapy. we opted to focus initially on teaching the Current attempts to teach even 3 different forms common factors in psychotherapy that pos- of psychotherapy as currently required by the itively affect psychotherapy outcomes. This Accreditation Council of Graduate Medical Educa- article reviews 6 such broad common factors. tion (ACGME)—cognitive-behavioral therapy, psy- (Journal of Psychiatric Practice 2015;21; chodynamic psychotherapy, and supportive psy- 180–189) chotherapy—have been disappointing. A survey of psychiatric residencies in the United States4 indi- KEY WORDS: common factors, integrative psycho- cated that residents graduate from training therapy, psychiatric residency education, psycho- “knowing” much about 1 and sometimes 2 forms of therapy outcomes the required psychotherapies. This means that, at best, residents graduate with competence in 1 form of psychotherapy and know a little about one other school of psychotherapy. In Alice in Wonderland, the Dodo bird famously As teachers of psychotherapy what are we to do? declaimed, “Everybody has won, and all must have Should we apply the “Dodo Bird Verdict” to training prizes!” The same phrase, the so-called “Dodo Bird in empirically supported psychotherapies? Should Verdict,” has been applied to controversies sur- we be expected to teach the 10 to 20 forms of rounding the comparative effectiveness of all psy- chotherapies. The “Dodo bird verdict,” which is contested, does not mean that all of the over 400 FEINSTEIN, HEIMAN, and YAGER: Department of Psy- 1 chiatry, School of Medicine, University of Colorado, Aurora, forms of psychotherapy are equally effective. An CO. excellent review of many meta-analyses2 conducted Copyright © 2015 Wolters Kluwer Health, Inc. All rights in the past 5 to 7 years summarizes the relative reserved. “ superiority of various empirically supported treat- Please send correspondence to: Noa Heiman, PhD, Depart- fi ments (ESTs)” for speci c conditions or problems. ment of Psychiatry, University of Colorado, 13001 E. 17th As codified by the Society of Clinical Psychology Place, MS F546, Aurora, CO 80045 (e-mail: noa.heiman@ (Division 12 of the American Psychological Associ- ucdenver.edu). ation), the standards for designating a psychother- The authors declare no conflicts of interest. apy as evidence-based require that a psychotherapy DOI: 10.1097/PRA.0000000000000064 180 May 2015 Journal of Psychiatric Practice Vol. 21, No. 3 Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited. COMMON FACTORS AFFECTING PSYCHOTHERAPY OUTCOMES designated psychotherapies when psychiatric resi- after common foundational concepts and skills are dents are not yet widely successful at achieving acquired during the first 2 years of residency does competence in the minimum of 3 forms of psycho- our Psychotherapy Scholars Track at the University therapy required by the ACGME? of Colorado Medical School also address specific To contend with these challenges, 1 popular schools of psychotherapy. strategy adopted by many training programs has The literature reviewed below has helped us been to teach easier to learn school-based psycho- develop the core principles that serve as our foun- therapies first. This approach emphasizes basic dation for teaching psychotherapy. school-specific psychotherapy concepts and skills, and then adds teaching and supervision for more complex forms of psychotherapy during advancing SIX COMMON FACTORS AFFECTING stages of training. The McMaster Psychotherapy PSYCHOTHERAPY OUTCOMES Program5 has used this strategy. Their system begins by teaching emotion-focused psychotherapy In his classic analysis, Persuasion and Healing, first early in training because it is foundational, published in 1961 and revised in a third edition emphasizing listening, empathy, and under- with his daughter Julia as co-author, Jerome standing emotions as basic skills required for Frank8 argued that change in psychotherapy occurs practicing other forms of psychotherapy. This pro- when factors that are common to all forms of psy- gram progresses in its teaching to cognitive-behav- chotherapy operate in concert. His list of common ioral therapy, to psychodynamic psychotherapy, factors included an emotionally charged confiding and on to other more specialized forms of treatment. relationship; the presence and encouragement of An alternative strategy for teaching psychother- hope; placebo effects; a healing setting; a mutually apy is to focus on the common factors that positively accepted conceptual scheme and belief system about affect psychotherapy outcomes. By distilling and the causes and cures of the maladies shared by both summarizing the common features of many schools healer and patient; therapeutic ritual; a warm, of psychotherapy, this perspective can generate its inspiring, and socially sanctioned therapist; explo- own core principles regarding psychotherapy edu- rations of one’s inner world; opportunities for cation, training, and practice. These principles can catharsis and acquisition and practice of new be translated into specific instructional and clinical behaviors; therapeutic suggestions; and inter- practice goals and objectives; these principles have personal learning. Persuasion and Healing stands informed our curriculum and are described else- as a cornerstone of scholarship into the common where.6 Learning multiple psychotherapies simul- factors, and this book is required reading for all taneously often leads the novice resident to feel residents in our Psychotherapy Scholars Track. confused and overwhelmed.7 The common factors Consistent with Frank’s initial writings a large approach offers the potential advantage of body of research has further contributed to our decreasing such confusion and can facilitate resi- understanding of common factors affecting psycho- dent acquisition of foundational therapeutic skills. therapy outcomes, and several models using these In addition, and of great practical importance, the factors in psychotherapy teaching have appeared. common factors approach relieves programs of the For example, the Y model9 offers an integrated burden of finding “good” patients to match the model for teaching psychotherapy competencies particular form of treatment the residents are try- across the 3 required schools of therapy (supportive, ing to learn. In this approach, all patients are “good” psychodynamic, and cognitive-behavioral thera- patients for learning something about psychother- pies). The stem of the Y refers to the common fea- apy. The common factors approach encourages tures of psychotherapy shared across schools and clinicians to focus on specific patients and problems includes within it supportive therapy, whereas the at specific points in time, utilizing specific inter- branches of the Y refer to the unique defining fea- ventions and tactics from various schools. It places tures of psychodynamic therapy and cognitive- interventions at center stage in psychotherapy behavioral therapy. According to the Y model, the training and practice rather than emphasizing common features across schools are alliance, theories or schools of psychotherapy. Thus, only assumptions about effectiveness, combined Journal of Psychiatric Practice Vol. 21, No. 3 May 2015 181 Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited. COMMON FACTORS AFFECTING PSYCHOTHERAPY OUTCOMES TABLE 1. Factors That Affect Although the Y model emphasizes treatment Psychotherapy Outcomes modalities and technique for teaching, our own design for teaching psychotherapy led us to broadly consider Effective in improving psychotherapy outcomes 6commonfactorsthataffectpsychotherapy outcomes. Certain patient characteristics improve the Although there may be room for debate as to which chances for positive psychotherapy