The antagonism between the common-factors explanation and the specific- techniques explanation of psychotherapeutic effectiveness has been and still is a topic of heated debates. In our opinion, however, this antagonism is likely mis- guided. To a considerable degree, the respective debates in psychotherapy research have been sham battles because techniques and common factors, including therapist effects, are not independent of one another. Therefore, popular accounts of the percentages of contributions of different therapy factors such as detailed by Lambert and others (Fig. 3.1) may have merits on the one hand because they integrate the available research evidence and thefindings of meta-analyses, but on the other hand, they apparently rely on the assumption of additivity.
It is however not possible to just sum up the respective contributions of common factors and techniques because the additivity assumption does not hold. Common
3.3 A Hierarchical Model of Therapeutic Factors 37
factors and techniques are intrinsically correlated in psychotherapy—specific inter- vention techniques are the very instruments by which therapists generate common factors. Hence it would be a dubious conception to add their respective percentages concerning therapy success and then claim, for instance, that one type of interven- tion, the common factors, would be three times more important for therapy outcome than the other.
We have recently initiated a project on the taxonomy of psychotherapy in order to study common factors and techniques not as additive components but as correlated ingredients of psychotherapeutic processes (Tschacher et al., 2014). Common factors and techniques are accordingly placed at different levels in the hierarchical system of all psychotherapeutic variables that constitute therapy process. In a survey among senior psychotherapists and psychotherapy researchers, we therefore asked these experts to assess if, and how much, a certain common factor (Table3.1) was implemented by techniques. In the study, the experts were presented the list of standard techniques printed in Table3.2to perform their ratings.
One of thefindings was that, as expected, all common factors are linked to sets of several techniques. The personality of a common factor is thus the profile of specific techniques that are positively associated with the generation of this factor, together with those techniques that hinder the expression of this factor. Figure3.2 shows a detail of this hierarchical system of variables that in their entirety make up psychotherapy process.
As a result, wefind that the relationships between psychotherapeutic interven- tions are best modeled as hierarchical. This is reminiscent of the classification Fig. 3.2 Hierarchical system of psychotherapeutic interventions. Arrows represent significant associations and factor loadings, both based on survey data (Pfammatter & Tschacher,2016;
Tschacher et al.,2014). Red broken arrows, significant negative associations. Reading example:
the techniques“Role play”and“Reality testing”implement the common factor“Self-efficacy,” whereas“Transference interpretation”reduces“Self-efficacy.” “Self-efficacy”in turn belongs to the top-level class of“Coping with problems”
system of psychopathology presented in the previous chapter, where we argued for a dimensional understanding of psychopathological states and, correspondingly, arrived at a hierarchical bottom-up system of psychopathology.
Starting in Chap.5, we will start to dissolve the supposed antagonism ofeither common factorsortechniques as effective interventions in psychotherapy. Wefind that the two types of intervention likely entail two different types of effects, which can befit into our modeling of therapeutic processes by stochastic and deterministic components. This is an alternative reading of Wampold’s (2015) distinction between the “medical model,” which assumes only specific techniques to be effective— Wampold believes this is unfounded—and his“contextual model”of psychother- apy, which represents Wampold’s conviction that only common factors are effective.
We have criticized this antagonism above for the reason that common factors and techniques simply constitute different levels of a hierarchy of interventions and therefore cannot be compared to one another with respect to their effectiveness.
A further critical point is the terminology used: the“medical model”is an unfortu- nate concept as obviously behavior therapy, which adheres to this specific interven- tion model, is still not a medical therapy.
Yet we believe we can synthesize and thereby partially support Wampold’s differentiation. Interventions at the level of common factors, thus contextual inter- ventions, generate a qualitatively different type of effect compared to interventions using specific techniques. Contextual interventions can instigate phase transitions, i.e., qualitative changes of the attractor landscape of the system under therapy, whereas specific interventions that function by the application of techniques rather change the states of variables in a given landscape or shift the attractor to a different place in state space (Chap.5). We consider both technical and contextual interven- tions as deterministic, and both depend on each other.
A number of research questions originate from the hierarchical view of psycho- pathology and the hierarchical view of psychotherapeutic interventions:
– Is there a correspondence between the two hierarchical systems, that of psycho- pathology and that of psychotherapeutic interventions? Such correspondence may mean that lower-level symptoms would be best treated by lower-level techniques, and, respectively, interventions concerning spectrum-level psycho- pathology should focus on contextual interventions at the level of common factors or classes of common factors.
– Are the interrelations of psychotherapeutic interventions as in Fig.3.2a general finding, or are they different in the treatment of different disorders?
– The system of interventions is as yet only based on expert ratings. Will empirical naturalistic studies in the field of psychotherapy, where techniques can be assessed by therapists, and common factors by their clients, result in the same relationships?
At this moment, these questions are unanswered.
In Chap. 1, we have made the assumption that the dynamics unfolding in psychotherapy is the result of both chance and causation. Therefore we wish to model how the application of some intervention changes the probability distribution and the attractor of some disorder. The ultimate goal of our agenda shall be a general
3.3 A Hierarchical Model of Therapeutic Factors 39
model of therapeutic change processes. Additionally, we wish to derive methods that will help us estimate the underlying attractors and distributions and their therapy-induced changes. In the next chapter, we will continue by proposing a general mathematical model of change processes.
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