Research: Therapeutic Common Factors in Different Modalities of Psychotherapy

There are as many styles of psychotherapy as there are therapists. Within modalities of psychotherapy, one would learn that the art snd style of the therapist’s work are unique to the person of the therapist in relation to the personality of the client.

In this article, I would like to highlight the concept of common factors among all psychotherapeutic work. The significance of the common factors are well established in psychotherapy research (Budge & Wampold 2015).

Verhaeghe, a critic of the mental health profession in general, mentions this:

“It has recently become increasingly clear that the effective factors in therapeutic practice are very much the same, beyond and above the various different paradigms. Every theoretically based clinical practice (psychoanalytic, cognitive behavioral, systemic, experiential . . . ) has its good and bad therapists, and this evidently has less to do with the particular theory than with the way these therapists are (un-)able to handle these common factors (Verhaeghe, 2008. p.72)”

What are the common factors? A meta-study

The meta-study by Grencavage & Norcross (1990) on the common factors that are attributed to psychotherapeutic change process are as follows:

Client Characteristics

  • Positive expectation/hope or faith
  • Distressed or incongruent client
  • Patient actively seeks help

Therapists Qualities

  • General positive descriptors
  • Cultivates hope/enhances expectancies
  • Warmth/positive regard
  • Empathic understanding
  • Socially sanctioned healer
  • Acceptance

Change Processes

  • Opportunity for catharsis/ventilation
  • Acquisition and practice of new behaviors
  • Provision of rationale
  • Foster insight/awareness
  • Emotional and interpersonal learning
  • Feedback/reality testing
  • Suggestion
  • Success and mastery experiences
  • Persuasion
  • Placebo effect
  • Identification with the therapist
  • Contingency management
  • Tension reduction
  • Therapist modeling
  • Desensitization
  • Education/information provision

Treatment Structure

  • Use of techniques/rituals
  • Focus on “inner world7exploration of
  • emotional issues
  • Adherence to theory
  • A healing setting
  • There are participants/an interaction
  • Communication (verbal and nonverbal)
  • Explanation of therapy and participants’ roles

Therapeutic Relationship

  • Development of alliance/relationship (general)
  • Engagement
  • Transference

The therapeutic alliance, described as “the quintessential integrative variable” (Wolfe & Goldfried, 1988) and probably the most often cited “common factor” in psychotherapy (Wampold, 2001).

What does this tell us?

The process of change in psychotherapy is a client-therapist dynamic. It is however, the job of the therapist to be effective. In return the client can be trusted to want to go through with the work for his/her own benefit.

That the psychotherapeutic theory alone is not listed explicitly as a common factor, tells us that it is the relationship and the contract to work is important. Education and continued self-awareness of the therapist determines how well the therapist can work with the client, and provide the necessary qualities that the client needs in the therapeutic sessions.

Bibliography

Budge, S. L., & Wampold, B. E. (2015). The relationship: How it works. In Psychotherapy research (pp. 213-228). Springer Vienna.

Grencavage, L. M., & Norcross, J. C. (1990). Where are the commonalities among the therapeutic common factors?. Professional Psychology: Research and Practice21(5), 372.

Verhaeghe, P. (2008). On being normal and other disorders: A manual for clinical psychodiagnostics. Karnac Books.

Wampold, B. E. (2001). The great psychotherapy debate: Models, methods, and findings. Mahwah, NJ: Erlbaum.

Wolfe, B. E., & Goldfried, M. R. (1988). Research on psychotherapy integration: Recommendations and conclusions from an NIMH workshop. Journal of Consulting and Clinical Psychology, 56, 448–451.

Research: CCRT Method comparison of Personality Organization

Diguer et.al (2001) used the Core Conflictual Relationship Theme (CCRT) method to differentiate between patients diagnosed with psychotic, borderline and neurotic personality organizations (PO). This model of  3 POs — the psychotic, the borderline and the neurotic– is the work of Otto Kernberg in 1984. Refer to these articles: Normal Personality Traits vs. Personality Disorders, Working with the Antisocial and Malignant Narcissistic Personality Disorder Spectrum . 

This is the abstract of the paper:

Screen Shot 2017-12-08 at 12.56.29

Participants in the research were evaluated with SCID-I and SCID-II plus other diagnostic instruments, one of which is the Personality Organizations Diagnostic Forms (PODF) by Diguer & Normandin (1997), which is an observer rated scale. They were then asked to give 10 narratives relating to incidents or events in relation to another person, according to the Relationship Anecdotes Paradigm (RAP) interview method by Lubrovsky (1998). Participants were also asked to describe 3 significant others as well as themselves according to Object Relationship Inventory (ORI). In all over 800 narratives were collected.

The test revealed little differentiation between the 3 PO groups of patients, although in the graph below one can see that the PPO group rated less (were less pervasive) in most categories, their results were also less negative. There are many factors that can account for this. I am not discounting for the possibility of medication as affecting the results. Kernberg also mentions that there is more repression going on with people with this condition.

Screen Shot 2017-12-08 at 13.51.14

The article also alluded to the non-significance of measuring more than the dimensions of WS, RS, WO and RO, due to the psychoanalytic theory of displacement.

Other studies were also mentioned in the paper with pointed towards a general negative rating of ROs and RSs, even in non-clinical samples. This alludes to the general tendency of people to remember the negatives better, and that these are unfinished businesses.

 

My Comments and Notes

I was looking forward to seeing marked differences in their results, however, this article provides an explanation for what the CCRT method is not effective at doing, and that is , making general comparisons of different groups of people.

The other question I have is, if it is justified to measure a predicate as “negative” or “positive”.

“Negative defines a reaction that is restrictive to the patient’s fulfillment of a wish, and positive means that a patient’s wishes have been fulfilled. (Stirn et. al, 2005)”

Could it be useful to used this method to observe how the predicates change for each client over time. E.g. RO (controlling) –> RO (likes me) ?

Source:

Diguer, L., Lefebvre, R., Drapeau, M., Luborsky, L., Rousseau, J. P., Hébert, E., … & Descôteaux, J. (2001). The core conflictual relationship theme of psychotic, borderline, and neurotic personality organizations. Psychotherapy Research11(2), 169-186.

Stirn, A., Overbeck, G., & Pokorny, D. (2005). The core conflictual relationship theme (CCRT) applied to literary works: An analysis of two novels written by authors suffering from anorexia nervosa. International Journal of Eating Disorders38(2), 147-156.

Research: CCRT used to study Gestalt and Emotive Behavioral Therapy

CCRT is employed in this research paper to study Gestalt and Emotive Behavioral Therapy sessions with adolescence.

With a standard treatment CCRT, 4 sessions are analyzed, 2 early

and 2 late with around 20 RE’s in all.

“In this study, only one therapy session for each of two clients was available and, therefore, only single session CCRT’s were formulated. A session CCRT is said to be “a special version of the CCRT and may differ slightly from the treatment CCRT” (Luborsky, 1990b, p. 32). “

Therefore n=2.

“Relationship episodes (RE’s) were demarcated on the written transcripts and judged as to their completeness. When the RE’s judged complete enough for the study were isolated, they were then examined for the three major components: wishes, responses from others and responses from self. A set of standard categories is available for describing the three components of the CCRT (Barber, Crits Christoph & Luborsky, 1990).”

“The standard category system is recommended for use with research while a tailor-made system seems to be more useful for clinical work. The second edition of the standard category system was used in this study. After each component was categorized, those occurring with the greatest frequency across RE’s were drawn together and the clients’ CCRT’s were formulated. A comparison was then made between the two treatment orientations.”

 

 


Bibliography

 

Agin, S., & Fodor, I. E. (1996). The use of the Core Conflictual Relationship Theme method in describing and comparing gestalt and rational emotive behavior therapy with adolescents. Journal of rational-emotive and cognitive-behavior therapy, 14(3), 173-186.

Research: CCRT-LU

  • Albani et. al (2002) introduces their revised version of Lubrovsky’s Core Conflictual Relationship Theme instrument, used in psychotherapy research. Read about the CCRT method here.

One of the main changes of the CCRT in CCRT-LU is the an introduction of “sub-dimensions of direction” subject-object and object-subject classification of wishes and responses. Whereas CCRT has got 4 main component dimensions (WO, RO, WS, RS), CCRT-LU has got 8 dimensions (WOO, WOS, WSS, WSO, ROO, ROS, RSO, RSS).

These dimensions are coded according to terms in the predicate lists.

 

 

Albani, C., Pokorny, D., Blaser, G., Gruninger, S., Konig, S., Marschke, F., … & Kachele, H. (2002). Reformulation of the core conflictual relationship theme (CCRT) categories: The CCRT-LU category system. Psychotherapy research12(3), 319-338.

Research: CCRT Method used to analyze Literature

This short note features the work of Stirn et.al. (2005) entitled, An analysis of two novels written by authors suffering from anorexia nervosa. 

The methodology was to analyze 2 novels written by 2 different authors who are known to have survived anorexia nervosa.

ABSTRACT

Objective: Two literary works of authors suffering from anorexia nervosa were analyzed with the method of the core conflictual relationship theme (CCRT) to prove that novels and/or personal accounts may reveal the same maladaptive relationship patterns typically revealed in psychotherapy sessions with this nosologic group.

Method: Two novels,  Valerie Valere’s The House of the Crazy Kids and  Andrea Graf’s Die Suppenkasperin, were selected which promised applicability of the CCRT method due to the completeness of the described relationship episodes.

Results: After several methodologic adjustments, the application of the CCRT method revealed the different courses and developments of the novels. Both the positive and negative as well as the conscious and unconscious relationship patterns were clearly expressed.

Screen Shot 2017-12-08 at 14.37.57

Discussion: The results indicate that after certain adjustments, the CCRT method may be successfully applied to data obtained from sources other than psychotherapy sessions.

More examples of tables:
Screen Shot 2017-12-08 at 14.38.48Screen Shot 2017-12-08 at 14.38.54Screen Shot 2017-12-08 at 14.39.11

Stirn, A., Overbeck, G., & Pokorny, D. (2005). The core conflictual relationship theme (CCRT) applied to literary works: An analysis of two novels written by authors suffering from anorexia nervosa. International Journal of Eating Disorders38(2), 147-156.

Research: Generic Change Indicators (CGI)

Mentioned in the article by Krause et.al (2007), the indicators towards the evolution of change in a psychotherapy treatment are as listed:

  1. Acceptance of the existence of a problem
  2. Acceptance of his or her limits and of the need for help
  3. Acceptance of the therapist as a competent professional
  4. Expression of hope (‘‘morale boost’’ or ‘‘remoralization,’’ the expectation of being helped or being able to overcome the problems)
  5. Questioning of habitual understanding, behavior, and emotions (‘‘opening up’’; may imply the recognition of problems previously ignored, self-criticism, and the redefinition of therapeutic expectations and goals
  6. Expression of the need for change
  7. Recognition of his or her own participation in the problems
  8. Discovery of new aspects of self
  9. Manifestation of new behavior or emotions
  10. Appearance of feelings of competence
  11. Establishment of new connections among aspects of self (e.g., beliefs, behavior, emotions); aspects of self and the environment (persons or events); aspects of self and biographical elements
  12. Reconceptualization of problems or symptoms
  13. Transformation of valorizations and emotions in relation to self or others
  14. Creation of subjective constructs of self through the interconnection of personal aspects and aspects of the surroundings, including problems and symptoms
  15. Founding of the subjective constructs in own biography
  16. Autonomous comprehension and use of the context of psychological meaning
  17. Acknowledgment of help received
  18. Decreased asymmetry between patient and therapist
  19. Construction of a biographically grounded subjective theory of self and of his or her relationship with surroundings (global indicator)

Qualitative Method of Measuring Change:

 

Source:

Krause, M., De la Parra, G., Arístegui, R., Dagnino, P., Tomicic, A., Valdés, N., … & Ramírez, I. (2007). The evolution of therapeutic change studied through generic change indicators. Psychotherapy research17(6), 673-689.

Research: Qualitative Method of Measuring Change

Qualitative Method of Measuring Change:
Theoretical correspondence: Change agrees with the contents of a generic change indicator.

Verifiability: Change is observed in the session (or, in the case of an extrasession change, it is
mentioned during a session and an explicit reference is made to therapy).
Novelty: The specific content of change manifests for the first time.
Consistency: Change is consistent with nonverbal communication and is not denied later in the
session or the therapy. On the basis of these four criteria and on the
descriptions of the CIs contained in the hierarchy, the research group identified and then coded all the
in-session and extrasession change moments for each therapy under study, following the procedure described previously.

 

Source:

Krause, M., De la Parra, G., Arístegui, R., Dagnino, P., Tomicic, A., Valdés, N., … & Ramírez, I. (2007). The evolution of therapeutic change studied through generic change indicators. Psychotherapy research17(6), 673-689.

Instruments used to Collect Data in Psychotherapy Outcome Research

List of questionnaires as instruments to track psychotherapy outcome in research.

Beck Depression Inventory (BDI) Symptoms Self-report C Beck et al. (1961)

Symptom Checklist- 90-R (SCL-90-R) Symptoms Self-report C Derogatis et al. (1976)

State-Trait Anxiety Inventory (STAI) Symptoms Self-report C Spielberger et al. (1983)

Dysfunctional Attitudes Scale (DAS) Vulnerability Self-report C Weissman and Beck (1978)

Clinical Outcome Routine EvaluationOutcome Measure (CORE-OM) Symptoms, well-being Self-report C Evans et al. (2002)

Outcome Questionnaire- 45 (OQ-45) Symptoms, interpersonal problems Self-report C Lambert et al. 2004

Inventory of Interpersonal Problems (IIP) Interpersonal problems Self-report C Horowitz et al. (1988)

Rosenberg Self-Esteem Scale (RSES) Well-being Self-report C Rosenberg (1965)

Post-Therapy Questionnaire (PTQ) Treatment goals Self-report C Mintz et al. (1979)

Patient Target Complaint (PTC) Treatment goals Self-report C Battle et al. (1966)

Hamilton Rating Scale for Depression (HRSD) Symptoms Observational J Hamilton (1960)

Structured Clinical Interview for DSM personality disorders (SCID-II) Personality Observational J Spitzer et al. (1990)

Shedler-Westen Assessment Procedure (SWAP-200) Personality Observational J Shedler and Westen (2007)

Global Assessment Scale (GAS) Treatment goals Observational J Endicott et al. (1976)

Therapist Target Complaint (TTC) Treatment goals Observational J Battle et al. (1966)

Source

Gelo, O. C. G., & Manzo, S. (2015). Quantitative approaches to treatment process, change process, and process-outcome research. In Psychotherapy Research (pp. 247-277). Springer Vienna.

Psychodynamic Interventions Rating Scale (PIRS)

The PIRS, categorizes each individual intervention. It allows for examining the therapy process at the level of moment-to-moment interactions apart from summarizing techniques used for the session overall.

 

 

 

 

Milbrath, C., Bond, M., Cooper, S., Znoj, H. J., Horowitz, M. J., & Perry, J. C. (1999). Sequential consequences of therapists’ interventions. The Journal of psychotherapy practice and research8(1), 40. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3330527/

Comprehensive Psychotherapeutic Interventions Rating Scale (CPIRS)

The Comprehensive Psychotherapeutic Interventions Rating Scale (CPIRS) was designed to study different orientations of psychotherapy used in researched practices. It is a way to measure treatment adherence and/or treatment differentiation.

Psychotherapeutic methods described in this scale

Client Centered, psychodynamic, behavioral, cognitive, group psychodynamic, and systemic orientations are included in the CPIRS.

Apart from these orientations, interventions and attitudes derived from common factors are included. The scale is also useful in determining how far the treatment is eclectic/integrative or pure form.

Items of the Interventions Rating Scale

 

Validity Studies

3 Studies were carried out, that are also presented in this article to validate this scale.

The first 2 studies indicated unconvincing differentiation between psychodynamic therapies and experiential therapies studied.  The differentiation was clearer in the third study.

General Conclusion


Bibliography

Trijsburg, R. W., Frederiks, G. C., Gorlee, M., Klouwer, E., den Hollander, A. M., & Duivenvoorden, H. J. (2002). Development of the comprehensive psychotherapeutic interventions rating scale (CPIRS). Psychotherapy Research12(3), 287-317.

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