EXPERT PSYCHOTHERAPISTS’ USE OF FOUR COMMON FACTORS IN PSYCHOTHERAPY A DISSERTATION SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY IN THE GRADUATE SCHOOL OF THE TEXAS WOMAN’S UNIVERSITY DEPARTMENT OF PSYCHOLOGY AND PHILOSOPHY COLLEGE OF ARTS AND SCIENCES BY KYLE M. ERWIN, B.A., M.A. DENTON, TEXAS DECEMBER 2015 Copyright © Kyle M. Erwin, 2015 all rights reserved. iii DEDICATION For Mom, Dad, Trisha, Stephen, Will, Rhyder, and Joe iv ACKNOWLEDGMENTS I gratefully acknowledge the exceptional individuals and works that contributed to this dissertation. I want to acknowledge and express my gratitude for the influence of Duncan’s (2010) On Becoming a Better Therapist. I heavily drew from this work to develop and define the four common factors underlying the majority of therapy outcomes. Moreover, I used Ducan’s work as a beacon of light to focus my research efforts on the most eminent and important works related to common factors. In doing so, I developed an excellent foundation for the common factors portion of the literature review and methods section. To lay the foundation of and write the methods section of the proposed research, I unashamedly drew from Hill’s (2012) Consensual Qualitative Research: A Practical Resource for Investigating Social Science Phenomena. Like Duncan’s work, Hill’s book provided useful references for primary sources that undoubtedly added to the depth of the methods section and my understanding of consensual qualitative research. Ericsson, Charness, Hoffman, and Feltovich’s (2006) The Cambridge Handbook of Expertise and Expert Performance provided a wealth of information on the history, development, and research base related to expertise and expert performance. The Handbook provided invaluable information about the criteria for selecting an exceptional sample of experts v and direct guidance regarding the appropriate means of data collection (i.e., direct observation). I used Skovholt and Jennings’s (2004) Master Therapists: Exploring Expertise in Therapy and Counseling as the foundation for my review of the empirical literature on expert psychotherapists, and as a guide for finding initial primary sources of research related to expertise in counseling and psychotherapy. These primary sources allowed for greater in-depth examination of the research. Moreover, primary sources provided an array of exceptional references for empirical data that supported the breadth of my review in this area. I also owe special acknowledgement to Scott D. Miller, Ph.D., for his eloquent address at the 2014 Evolution of Psychotherapy conference and John Thomas’s (2014) summarization, Therapy: No improvement for 40 years. Thomas’s summarization provided an excellent outline for the introduction section of this research and added motivation for my personal desire to achieve and sustain clinical excellence throughout my career. Jeff Harris, Ph.D., I owe special acknowledgement to you as you have been my dissertation chair and mentor through this arduous stage of training. You supported my lofty creative side by listening to my ideas and conceded my strengths of passion, creativity, and noble aspirations. At the same time, you tactfully and gently guided me to contain my passion as we narrowed down the focus of this research into a reasonable viii project. Additionally, you provided excellent motivational coaching as you inspired me to write, an extremely difficult endeavor since I hate writing and experienced this process as soul-draining, futile, and barbaric at least 90% of the time. Sally Stabb, Ph. D., I am especially grateful for and appreciate your passion for qualitative inquiry and willingness to share your time on my committee. You provided my first exposure to qualitative methods of inquiry and opened my eyes to ways of knowing that fit with my being. In doing so, you provided the means for my increased experience of personal integrity in the countless hours I devoted to this research. As a result, I experienced my working hours as more meaningful and fitting with my values. Thank you. Abigail C. Tilton, Ph.D., you have been a fellow research team member, boss, mentor, consultant, co-author, and friend during my time at TWU. You allowed me to be me throughout our time together. You embraced me and extended considerable patience and personal time to support, understand, and validate the emotional, intuitive, and justice-seeking soul residing in my body. Your validation and support here kept my soul alive. As a result, I had the energy to continue through several soul-crushing experiences on the journey to today. At the same time, you mentored and taught me how to contain my more idealistic notions, immature impulsiveness, personal vanity, and unrealistic expectations. In doing so, I learned how to navigate the inherent interpersonal and political aspects of professional and academic success more successfully. You are truly one of the most interpersonally gifted academics I have met. ix You are a talented leader and I look forward to your future achievements in academic leadership. Jeff Strain, Ph.D., your presence was a gift during my graduate experience. Without your support and encouragement, I am certain I would not be at this exciting juncture in my personal and professional life. Even before my arrival at graduate school, I feel my undergraduate experiences at Baylor University and the University of Texas at Dallas formed the foundation for my continued growth and development in graduate school. I am especially grateful to Gary Brooks, Ph.D.; Michel Frisch, Ph.D.; Hugh Riley, Ph.D.; David Rudd, Ph.D.; and Susan Spooner, Ph.D. Over the course of eight years, I found support among numerous faculty, staff, and students at TWU. Additionally, I experienced incredible growth due to my work with clinical supervisors and colleagues at North Lake College, Youth First Texas, the Veterans Affairs North Texas Health Care System, and the Lexington VA Medical Center. There is so much I would like to acknowledge and write about each of you, but will conclude by mentioning you by name. Thank you! Department of Sociology and Social Work TWU Institutional Effectiveness Sandra Brackenridge, LCSW Carol Kominski, Ph.D Michele Bland, LMSW Lisa Haynes. Mark Sandel, LMSW Linda Marshall, Ph.D. TWU Academic Financial Services Nila Ricks, Ph.D. Mary Ann McDuff Daniel Taylor, LMSW-AP x Samantha Farmer TWU School of Management Barbara Byrd Becky Bryant, MBA Lisa Zottarelli, Ph.D. Ratonia Reynolds, Ph.D. TWU Law Enforcement Management Institute TWU College of Arts and Sciences Sally Reed, MA Ann Q. Staton, Ph.D. Cassandra Fulton-Withrow, MBA Rhonda Redfearn Anne Downing TWU Counseling Psychology Program TWU School Psychology Program Ryan Robinson, MA Denise Maricle, Ph.D. Sonal Gaind, MA Angela Mitchell, Ph.D. Sheila Pogge, Ph.D. Laura Sanders, Ph.D. Faye A. Reimers, Ph.D. Rachel Muenke, Ph.D. Keidy Ding, Ph.D. Neetha Devdas, Ph.D. TWU Mathematics Karen Bartlett, Ph.D. David Marshall, Ph.D. TWU Office of Research and Sponsored Programs Youth First Texas Jo Anne Hawthorne Judith Dumont, MA Tracy Lindsay Aimee McNamara, MA, LPC Bonnie King Brant Anderson, MA, J.D. Oliver Blumer, DC TWU Department of Psychology and Philosophy TWU Pioneer Center Kenneth Foster, Ph.D. Joshua Adams, Ed.D. Shannon Scott, Ph.D. Kurt Krause North Lake College VA North Texas HCS Avni Vyas, Ph.D. Stephen Holt, MD, MPH, MSNRS Howard M. Cunningham, Ph.D. Dr. Monique Mayo, Chiropractic Vickie Linden, LMSW Monique Mayo, D.C. Janine Lenger-Gist, LMSW Mayhill Hospital Behavioral Health Flint Sparks, LLC Kathy Holt, LMSW Flint Sparks, Ph.D. xi Lexington VAMC VA El Paso HCS Jennifer Kinder, Ph.D. Emilia A. Campos, Ph.D., ABPP Steven Hansel, Psy.D. Ashely Casto, Psy.D. Autumn McCane, Ph.D. Joshua Phillips, Ph.D. Larson Maggard, Ph.D. Cindy Robichaux, LCSW Scott Wilson, Psy.D. Jessica Wilson, Psy.D. Jeffery Pratt, Psy.D. xii ABSTRACT KYLE M. ERWIN EXPERT PSYCHOTHERAPISTS’ USE OF FOUR COMMON FACTORS IN PSYCHOTHERAPY DECEMBER 2015 A four-person research team used observation and structured qualitative analysis to examine and describe how five expert psychotherapists manifest four common factors central to psychotherapy outcomes. These factors fell into four domains (1) Therapy Alliance, (2) Enhancing Motivation, (3) Positive Expectation, and (4) Feedback. Five video streams of expert psychotherapists engaged in real psychotherapy sessions were directly examined by the four-person research team, made up of a doctoral candidate, two practicing psychotherapists, and a practicing professor of counseling psychology. Using a modified version of consensual qualitative research, the research team captured and classified the essence of verbal interventions by expert psychotherapists as they enacted the four common factors examined in this study. The research team coded almost 850 interventions into the four proposed common factor domains. Of the coded interventions, the research team coded almost 60% of the interventions in the domain of Therapy Alliance. The research team coded the remaining interventions into the domains of Positive Expectation (19.67), Enhancing Motivation (19.55%), and Feedback (2.26%). xiii To provide greater descriptive information of experts’ enactments of interventions in the four common factor domains, the research team identified 7 major categories and 37 simple categories and subcategories, each of which is discussed in detail in the results and discussion section of the work. Finally, I discuss the potential implications