Beruflich Dokumente
Kultur Dokumente
Do psychotherapies work primarily through the specific factors described in treatment manuals, or do they work Lancet Psychiatry 2017;
through common factors? In attempting to unpack this ongoing debate between specific and common factors, we 4: 953–62
highlight limitations in the existing evidence base and the power battles and competing paradigms that influence the Published Online
July 5, 2017
literature. The dichotomy is much less than it might first appear. Most specific factor theorists now concede that http://dx.doi.org/10.1016/
common factors have importance, whereas the common factor theorists produce increasingly tight definitions of bona S2215-0366(17)30100-1
fide therapy. Although specific factors might have been overplayed in psychotherapy research, some are effective for Department of Psychological
particular conditions. We argue that continuing to espouse common factors with little evidence or endless head-to-head Medicine, University of Otago,
comparative studies of different psychotherapies will not move the field forward. Rather than continuing the debate, Christchurch, New Zealand
(Prof R Mulder FRANZCP);
research needs to encompass new psychotherapies such as e-therapies, transdiagnostic treatments, psychotherapy
Department of Psychological
component studies, and findings from neurobiology to elucidate the effective process components of psychotherapy. Sciences, Swinburne University
of Technology, Hawthorn, VIC,
Introduction different psychological problems. These apparently Australia (Prof G Murray PhD);
and Psychology Department,
The aim of this Review is to discuss a pivotal debate from contradictory findings have led to two broad groupings of
University of Canterbury,
psychotherapy research: do psychological therapies work psychotherapy theorists: those emphasising relationship, Christchurch, New Zealand
primarily through the specific factors that are described in patient expectancy, and process (common factors), and (Prof J Rucklidge PhD)
treatment manuals (eg, cognitive restructuring in those emphasising procedural techniques (specific Correspondence to:
depression, or exposure in anxiety disorders), or do they factors). As observed by Norcross,18 “The culture wars in Prof Roger Mulder, Department
of Psychological Medicine,
work primarily through factors that are common across psychotherapy dramatically pit the treatment method
University of Otago,
most therapies (eg, positive working alliance and against the therapy relationship”. Christchurch 8140, New Zealand
expectation)? Empirically, the debate between specific Common factors should not be considered non-specific roger.mulder@otago.ac.nz
versus common factors centres on two findings arising in in the sense of being unintended benefits of therapy (like
repeated meta-analyses. First, psychotherapies are more the placebo effect). Indeed, most common factor theorists
effective than unstructured interactions and more effective consider these factors to collectively shape a theoretical
than nothing,1,2 and second, specific psychotherapies such model about the mechanisms of change in psychotherapy
as cognitive behavioural therapy (CBT), interpersonal (panel 2).20
therapy, mindfulness, and acceptance and commitment
therapy generally do not differ in effectiveness (panel 1).11,12 Fundamental disagreement about the basis of
These findings are exemplified by a network meta- psychotherapy
analysis13 of seven psychotherapeutic interventions for The history of psychotherapy research interacts with the
patients with depression. The investigators reported that, debate between common and specific factors. From the
although each intervention was better than a waitlist 1980s, psychotherapy research sought to shore up the
control, the relative effects of different psychotherapeutic status of psychological work through adoption of
interventions on depressive symptoms were similar. This a medical approach, with categorical diagnoses,
evidence suggests that factors shared across psychological randomised controlled trials, and a focus on treatment
therapies (ie, common factors) might be the major outcome.21 This approach also fitted comfortably with
therapeutic mechanism. The apparent importance of the cognitive behavioural therapies that had emerged
common factors has been characterised as the dodo bird from a tradition of objective analysis among researchers
effect, after the line in Alice in Wonderland (“At last the and clinicians who were comfortable with the medical
Dodo said, ‘Everybody has won, and all must have prizes’”).14 model.22 Indeed, the principal founder of CBT was
A highly cited 2002 review15 of 17 meta-analyses Aaron Beck, a psychiatrist by training. The consequence
comparing active treatments with each other showed was that the past 30 years of psychotherapy research has
small, non-significant differences in outcome, which paid disproportionate attention to treatment outcome,
diminished further after the substantial effects of with relatively little attention to the mechanism of
researcher allegiance were controlled for. However, these action of psychotherapies.23 This contingency, in turn,
and similar findings have been questioned by those explains key features of the existing psychotherapy
of other meta-analyses. Tolin,16 for example, reported literature.
that CBT was associated with a significant advantage First, CBT has become almost synonymous with
over other therapies, at least in patients with evidence-based psychotherapy. CBT has an explicit,
anxiety or depressive disorders. Similarly, Hofmann and theory-driven position about the steps necessary to
colleagues17 showed evidence for treatment specificity in achieve desired change, usually symptom remission.
a review of 269 meta-analytic studies examining CBT for Consequently, the competencies therapists require are
clear and the treatment is easily manualised, facilitating prioritised CBT as the psychotherapy having the most
CBT becoming the dominant training approach for evidence.24
psychotherapists worldwide. The ambitious Increased Second, we know that CBT (as the exemplar evidence-
Access to Psychological Therapies (IAPT) programme, based psychotherapy) is effective for a range of presenting
which provides a stepped care approach in England, has problems compared with several different comparators
but putative active ingredients. Interventions are complex corresponding problems with the alliance literature, in
multicomponent activities, and therapies are typically which measured alliance might in fact be a consequence
based on an individually tailored case formulation (at a rather than a cause of improved outcomes. Little research
minimum, weighting of different components of a has been specifically designed to parse out alliance effects.
manualised intervention to the needs of the case).23 The relationship between treatment adherence and the
Additionally, the dissemination of findings leads to therapeutic alliance was positive in some studies and
further bias. Negative trials are less likely to be reported, negative in others,46 highlighting the complexity in
thereby inflating effect sizes.37 Low-quality studies often identifying the variables essential for positive outcomes.
result in larger effect sizes.38 Trial registration is poor, so Regardless, common factor researchers argue that
we cannot know whether outcomes are selectively outcome studies do not answer the most important
reported, particularly by groups with a strong allegiance outstanding question in psychotherapy—namely, what
to the treatments. Findings from a 2017 systematic are the mechanisms of change? Although the importance
review39 showed that only 12% of psychotherapy trials of specific factors has been estimated from effect sizes
were prospectively registered with clearly defined primary of targeted therapies compared with plausible controls,
outcome measures. the importance of common factors has been estimated
One obvious approach to the dodo bird problem is to test correlationally through the association between therapy
whether different therapies do lead to different outcomes. outcomes and patient reports of rapport and engagement.
Head-to-head comparisons generally suggest small Although the effect sizes of targeted therapies compared
differential effects, which are smaller and non-significant with controls permit causal correlations, correlation
after researcher allegiance is controlled for.40 However, this between therapy outcomes and patient engagement
literature has substantial limitations. Most studies have does not, and will be confounded by an overlap between
investigated cognitive therapy or CBT as one of the the success of therapy and the client’s satisfaction with
treatment groups, so specific strengths of other approaches the therapist.47 Therapeutic alliance is fundamentally
are poorly understood. Only a narrow range of treatment dyadic (ie, a reciprocal working relationship), which sits
outcome measures have been systematically examined, uncomfortably with the more medical notion of patient
most typically acute symptom reduction; longer-term as recipient of the therapist’s activities.48
effects, including relapse prevention measures for Finally, psychotherapy research is difficult and
common chronic conditions, might differentiate some expensive to conduct, and—without the commercial
therapies for some problems. Differences might be investment that occurs in pharmacotherapy research—
revealed if a wider range of treatment outcome measures deficits of the existing evidence base are attributable
were used, including functioning, quality of life, and simply to the low power and small number of studies.49
individualised measures of treatment outcome.41 However, For example, although the effectiveness of behavioural
such trials are expensive and rarely undertaken. therapy for obsessive compulsive disorder is similar
Differences might also be larger if moderating factors such to that of pharmacological treatment, investigators of a
as individual differences between patients were accounted meta-analysis50 of psychotherapy and pharmacotherapy
for in outcome modelling. for obsessive compulsive disorder found 15 psychotherapy
Another way to test the specific factor model is through trials with a total 705 patients, by contrast with
therapist adherence. Improved adherence to theory- 32 pharmacotherapy trials with a total of 3588 patients.50
specified factors in evidence-supported therapies should
improve patient outcomes, if these specific factors are A false dichotomy?
important to the success of the therapy. However, the The common factor and specific factor positions might be
evidence has not generally supported this hypothesis, with less divergent than they at first appear. First, most specific
findings from a meta-analysis42 showing that neither factor theorists concede that common factors are
variability in competence nor adherence was related to important.51 They argue that their model allows for the
patient outcome, suggesting that these variables are existence of therapist effects, allegiance effects, and other
relatively inert therapeutic agents. The broader literature is common factors. Psychotherapy training programmes
split on this question, with some investigators finding no that prioritise CBT interventions for clinical problems, for
effect of treatment integrity on outcomes, some a positive example, typically commence with substantial training
effect, and some a negative effect (potentially due to an in so-called counselling skills, emphasising common
overly rigid application of technique, which could be factors such as engagement, optimism, positive regard,
detrimental to the therapeutic alliance for some clients).43 explicit collaboration, and structured goal setting.52
Extent of training might also not be relevant to outcome, as Similarly, at the level of published treatment manuals,
suggested by the work of Stanley and colleagues.44 Indeed, CBT has a strong focus on therapy process and tailoring
therapeutic alliance, a common factor, might be a more of the intervention to the particular client across time.53
important variable to instigate change than therapeutic Second, common factor theorists seem to be increasingly
adherence, although even these effect sizes are modest tightening their definition of bona fide therapy. They
(mean alliance–outcome correlation 0·26).45 There are suggest that the treatments must be delivered by trained
practice and training has improved the quality of service dismantling designs, the full treatment is compared with
provision and patient outcomes, and the implementation the treatment with at least one element removed; in
of the principles of evidence-based practice has enhanced additive designs, a component is added to an existing
the effectiveness of treatment and has almost certainly treatment to assess whether the addition improves
reduced harm. The pragmatic importance of structured outcome. In a classic dismantling study, Jacobsen and
psychotherapies having been extensively investigated colleagues70 showed that behavioural activation alone was
and found safe should not be underestimated. The as effective as full CBT for depression; this work was
controversy remains centred on the extent to which pivotal in bringing attention to therapeutic mechanisms.
psychotherapies have correctly identified whether their Findings from a meta-analysis49 of component treatment
specified components are responsible for the therapeutic studies showed that, for dismantling studies, there were
change, rather than challenging the usefulness of an no significant differences between the full treatment and
evidence-based approach. the dismantled treatment. However, the investigators
Although common factors are important in all reported that treatments with an additive component
psychotherapies, simply taking this approach alone is yielded a small but significant positive effect at completion
unlikely to lead to useful models for clinical practice. (d=0·14) and a slightly larger effect at follow-up (d=0·28).
There are virtually no experimental studies to support the This result was only for specific problems that were targets
hypothesis that common factors are sufficient to effect for treatment. These findings suggest that a strategy
change. There is no well argued theory that accounts for that starts with effective treatments and tests which
treatment outcome, let alone evidence about such a theory. components incrementally improve outcomes could be a
Neither espousal of common factors nor continued head- useful method to advance the development of psycho
to-head comparative studies of different psychotherapies therapies. However, researcher allegiance to the added
seems a satisfactory way to move the field forward. component might also explain some of the discrepancy
Arguably, the debate over common versus specific factors between additive and dismantling designs.49 Such studies
is a distraction from the urgent need to better understand might be consistent with stepped care approaches in
the mechanisms of action of psychological treatments. terms of determining the minimal amount of therapeutic
We suggest that there are at least four approaches input necessary to effect the largest amount of change in
which might be useful in the future. The first is the symptoms, allowing services to offer more cost-effective
transdiagnostic treatment approach. The second is to treatments.
develop component (ie, dismantling or additive) studies
to identify whether specific active ingredients contribute E-therapies
to differential outcomes. The third involves considering At present, online therapies range from fully self-guided
the implications of e-therapies, and the fourth is an approaches to real-time interactions with a therapist
aspirational call for a thoroughgoing clinical science. via the internet, with most internet research focusing
on low-intensity structured interventions (typically
Transdiagnostic treatments CBT) delivered with little or no online coaching
The transdiagnostic treatment approach highlights the support. In a review of more than 100 randomised
common factors in emotional disorders and uses unified controlled trials, Hedman and colleagues71 reported that
protocols instead of developing different treatment internet-delivered CBT produced similar outcomes to
protocols for each emotional disorder.69 This treatment conventional face-to-face CBT for the treatment of
includes specific approaches that are believed to transcend depression, anxiety, female sexual dysfunction, cannabis
diagnostic categories, including emotional regulation use, eating disorders, and pathological gambling. It was
components, cognitive reappraisal, and emotional aware less effective for social anxiety, obsessive compulsive
ness training.62 The unified protocol has demonstrated disorder, and bipolar disorder.
effectiveness in various disorders, including generalised At first glance, this pattern of findings suggests (contrary
anxiety, panic and agoraphobia, social anxiety, and major to the proponents of both common and specific factors)
depressive disorder.69 This approach demonstrates that the that, far from being sufficient, in certain circumstances a
process of learning to regulate emotions and modify therapeutic relationship might not even be necessary for
negative emotional experience can be construed as efficacy, although it is important to consider that an
an alternative common mechanism of change during e-therapy website offers a symbolic form of relationship.72
therapy.31 These transdiagnostic treatments often use Cultural artifacts (books, film, etc) are premised on such
group therapies, allowing large sample sizes to test for disembodied but nonetheless influential relationships.
mechanisms of change. Although very different from the traditional image of
a real-time healing encounter, engagement with an
Psychotherapy component studies e-therapy website (laden with evidence of benevolent
Component studies (dismantling or additive) identify therapeutic intention) might nonetheless constitute a
whether and in what circumstances specific active meaningful relationship with therapeutic benefits.
ingredients contribute to differential outcomes. In Indeed, research into online therapies highlights features
of this symbolic relationship as crucial for engagement approach to each of these domains of research, and their
and adherence (eg, demonstration of care, personalised weighting relative to each other, will vary. We propose that
treatment, and authentic communication).72 Future such assumptions are best made explicitly, and best
research investigating the role of specific and common recognised as social constructions in which empirical
factors will therefore need to consider the range of ways in research takes place (figure 2).
which a therapeutic relationship can be constructed. An emerging theme in theorising about psychotherapy
Additionally, consistent with the suggestion to is the embodied nature of human beings, counterbalancing
conduct more dismantling studies, e-therapies offer the the cognitivism of CBT, and encouraging consideration of
opportunity for sophisticated research to explore whether biobehavioural explanations of behaviour change.76,77
any specific components of therapy are necessary for For example, Lane and colleagues78 suggest that emotional
change to occur. Systematic manipulation of various arousal (updating of previous emotional memories through
putative mechanisms of change—including the presence a process of reconsolidation) is the key ingredient of
or absence of a therapist, specific treatment factors (eg, therapeutic change across a variety of psychotherapies.
type of exposure), specifics of cognitive coping skills to Ecker and colleagues79 propose a psychotherapy integrated
deal with distressing events or thoughts, and whether framework centred on the brain’s required steps to induce
homework is included—could enable clearer elucidation schema destabilisation and erasure. Neuroimaging studies
of the common or specific factors necessary for effective show decreased activity across several regions of the
change. Any component of CBT (including extent, dose, prefrontal cortex after multiple forms of psychotherapy for
and timing of therapeutic contact) can easily be depression.80 Goldin and colleagues81 showed that CBT for
manipulated as part of e-therapy in that modules and social anxiety disorder produced greater changes in the
content can be adapted using the programming algorithm. neural dynamics of patients than did a waitlist control. As
E-mental health programmes, even ones that are fully these investigators pointed out, future research could
automated, can differ in how much common factors are investigate how different forms of CBT (eg, individual vs
emphasised; the voices used, how responsive the group CBT) and other clinical interventions affect the
programme is to the data entered by the user, how much temporal dynamics of brain networks, and how these
communication is made on hope for improvement, and therapeutic effects generalise to other disorders. Although
how credible the illustrative characters are, can all increase this research is in its infancy, more complex multilevel
or decrease the presence of so-called common factors.72 models (and consequent investigation of the neurobiological
Such controlled dismantling, a strategy that is quite and psychological changes associated with psychotherapy)
achievable with e-therapy, could reveal the necessary and have the potential to elucidate how psychotherapeutic
sufficient components for treatment to result in change. treatments affect individuals.
unknown.75 While we await better understanding of evidence exists, such as post-traumatic stress disorder or
interventions, how should training be focused to support specific phobias.83 Future research into the dissemination
evidence-based practice in the community? One and implementation of evidence-based psychotherapy
pragmatic approach might be to continue to train practice could then test the effects on the community
therapists in CBT, the most robustly supported of such a hybrid approach.
psychotherapy approach; as noted above, it is a core However, we should not confuse evidence showing
element of the system-wide IAPT approach used in efficacy or even effectiveness with validation of a given
England. Ambiguous evidence for manual-driven practice therapy, and we should train therapists to be sceptical of
suggests that the primary focus of CBT training should be the recognised brands. In particular, it is clear that
on therapeutic principles rather than specific techniques.82 (within bona fide therapies), relationship factors might
Within this training, increased emphasis could be placed be doing as much of the work as specific techniques, and
on common factors such as warmth, hope, empathy, and trainee suitability should include consideration of such
alliance, alongside the principles of CBT (ie, that thoughts aptitudes. We should be alert to professional self-interest
are not facts, present focus, incremental change, etc). To and self-interested drivers that tend to overstate the
recognise evidence for some therapy-specific effects for importance of complex, difficult-to-teach therapeutic
certain disorders, it seems reasonable to augment skills (panel 3). It is interesting to note, for example, that
training in principles with additional modules focusing early analyses84 of the IAPT programme suggested no
on more specific techniques in different conditions where difference in outcomes between low-intensity and high-
intensity versions of CBT.
We argue that the inclusion of common factors
Panel 3: Implications for training
makes a strong case for increased research focus on
At least within bona fide therapies, common factors might be psychotherapy processes and mechanisms. This focus
doing as much of the work as specific techniques. Course could still be in the context of evidence-supported
content and trainee selection and assessment should reflect common therapeutic mechanisms, as well as the specific
this complex reality. factors currently emphasised (figure 2).26
Given the possibility that therapies are harmful (at least in
Future clinical trials in psychotherapy
terms of opportunity cost), preference should be given in the
Given the consistent small differences in comparative
training syllabus to brands that have been more widely studied
outcome trials of psychotherapy, it might be timely to
and critiqued, while holding in mind that evidence of efficacy
reconsider how this clinical research is best conducted.
and effectiveness is not equivalent to evidence of validity.
The most obvious problem is that, because the differential
As in other areas of health and medicine, therapists must effect size is small, clinical trials comparing different
tolerate working in the absence of clear supporting therapies would need to be very large to detect an effect. A
evidence in many cases. In this context, scepticism and review85 of psychotherapies in adult depression reported
open-mindedness are important intellectual attributes for that a trial to detect clinically relevant differences (which
the trainee therapist. Hopefulness and optimism are were calculated as d=0·24) would require 548 patients. A
important emotional attributes for the trainee therapist. meta-analysis49 of component treatment studies showed
that such studies would need 800 patients in each group
to detect short-term additive improvement, and 200 in
Search strategy and selection criteria each group for follow-up outcomes. Continued design and
We searched PubMed, PsycINFO, Web of Knowledge, and conduct of randomised controlled trials that are heavily
Google Scholar for articles published between Jan 1, 2000, and underpowered will only reinforce the dodo bird effect. The
Jan 1, 2016, with a range of terms including “psychotherapy”, future of clinical psychotherapy research might therefore
“common factors”, “specific factors”, “e-therapy”, “treatment be in large, pragmatic trials using structures such as
adherence”, “therapeutic alliance”, “evidence-based practice”, practice research networks. These trials could include
“transdiagnostic psychotherapy”, “psychotherapy e-therapies, group therapies, and face-to-face therapies.
components”, and “psychotherapy neuroscience”. We The psychotherapy initiative in public health services and
restricted the language to English. We selected papers from managed care could offer a platform to examine the effect
the identified publications based on the quality of research. of psychotherapies in large numbers of people in a real
Within topic areas with multiple studies, we selected recent clinical situation.
meta-analyses and systematic reviews and studies that
described new findings. In less well researched areas, we Conclusion
selected key papers and new findings. We supplemented the Common and specific factors in psychotherapy have been
search with earlier landmark papers as well as suggestions discussed for more than half a century. However, the
from the reviewers. These landmark papers included seminal debate is less dichotomised than it first appears. There is
theoretical papers and relevant professional position papers. some agreement that elements from treatment models
grounded in evidence-based practice, such as trained
therapists, credible psychological principles, and manual 19 Laska KM, Gurman AS, Wampold BE. Expanding the lens of
ised treatments, could contribute to the efficacy and safety evidence-based practice in psychotherapy: a common factors
perspective. Psychotherapy (Chic) 2014; 51: 467–81.
of psychotherapy. There is also agreement that common 20 Wampold BE. How important are the common factors in
factors, such as engagement, optimism, and explicit psychotherapy? An update. World Psychiatry 2015; 14: 270–77.
collaboration, improve outcome. There might be small 21 Goldfried MR. What should we expect from psychotherapy?
Clin Psychol Rev 2013; 33: 862–69.
but clinically relevant differences in aspects of specific
22 Deacon BJ. The biomedical model of mental disorder: a critical
factors, but these differences are difficult to detect due to analysis of its validity, utility, and effects on psychotherapy research.
poorly designed, underpowered trials. The future lies Clin Psychol Rev 2013; 33: 846–61.
with trying to understand more clearly the mechanism of 23 Herbert JD, Gaudiano BA. Moving from empirically supported
treatment lists to practice guidelines in psychotherapy: the role of
change associated with psychotherapy. This strategy will the placebo concept. J Clin Psychol 2005; 61: 893–908.
require different techniques, including large pragmatic 24 Fonagy P, Clark DM. Update on the Improving Access to
clinical studies, e-therapies, trans diagnostic treatment Psychological Therapies programme in England. BJPsych Bull 2015;
39: 248–51.
approaches, and increased understanding of neuro
25 Cuijpers P, Cristea IA, Karyotaki E, Reijnders M, Huibers MJ.
biological changes brought about by psychotherapy. How effective are cognitive behavior therapies for major depression
Contributors and anxiety disorders? A meta-analytic update of the evidence.
World Psychiatry 2016; 15: 245–58.
All authors contributed to the conceptualisation and writing of the paper.
26 Johnsen TJ, Friborg O. The effects of cognitive behavioral therapy
Declaration of interests as an anti-depressive treatment is falling: a meta-analysis.
We declare no competing interests. Psychol Bull 2015; 141: 747–68.
27 Lilienfeld SO, Ritschel LA, Lynn SJ, Cautin RL, Latzman RD.
References
Why many clinical psychologists are resistant to evidence-based
1 Goldin PR, Ziv M, Jazaieri H, et al. Cognitive reappraisal self-efficacy
practice: root causes and constructive remedies. Clin Psychol Rev
mediates the effects of individual cognitive-behavioral therapy for
2013; 33: 883–900.
social anxiety disorder. J Consult Clin Psychol 2012; 80: 1034–40.
28 Frank JD, Frank JB. Persuasion and healing: a comparative study of
2 Holmes MC, Donovan CL, Farrell LJ, March S. The efficacy of a
psychotherapy, 3rd edn. Baltimore, MD: The Johns Hopkins
group-based, disorder-specific treatment program for childhood
University Press, 1993.
GAD: a randomized controlled trial. Behav Res Ther 2014;
61: 122–35. 29 Norcross JC. Empirically supported therapy relationships:
summary report of the Division 29 Task Force. Psychotherapy 2001;
3 Hayes SC. Acceptance and commitment therapy, rational frame
38: 345–56.
theory, and the third wave of behavior therapy. Behav Ther 2004;
35: 639–65. 30 Roger CR, Skinner BF. Some issues concerning the control of
human behaviour; a symposium. Science 1956; 124: 1057–66.
4 Linehan MM. Cognitive behavioral treatment of borderline
personality disorder. New York, NY: The Guilford Press, 1993. 31 Mennin DS, Ellard KK, Fresco DM, Gross JJ. United we stand:
emphasizing commonalities across cognitive-behavioral therapies.
5 Shapiro F. The role of eye movement desensitization and
Behav Ther 2013; 44: 234–48.
reprocessing (EMDR) therapy in medicine: addressing the
psychological and physical symptoms stemming from adverse life 32 Hayes SC, Villatte M, Levin M, Hildebrandt M. Open, aware, and
experiences. Perm J 2014; 18: 71–77. active: contextual approaches as an emerging trend in the behavioral
and cognitive therapies. Annu Rev Clin Psychol 2011; 7: 141–68.
6 Frank E. Treating bipolar disorder: a clinician’s guide to interpersonal
and social rhythm therapy. New York, NY: The Guilford Press, 2005. 33 Malhi GS, Bassett D, Boyce P, et al. Royal Australian and
New Zealand College of Psychiatrists clinical practice guidelines
7 Bateman AW, Fonagy P. Mentalization-based treatment of BPD.
for mood disorders. Aust NZ J Psychiatry 2015; 49: 1087–206.
J Pers Disord 2004; 18: 36–51.
34 Kaplan BJ, Giesbrecht G, Shannon S, McLeod K.
8 Wells A. Metacognitive therapy for anxiety and depression.
Evaluating treatments in health care: the instability of a one-legged
New York, NY: The Guilford Press, 2011.
stool. BMC Med Res Methodol 2011; 11: 65.
9 Segal ZV, Williams JMG, Teasdale JD. Mindfulness-based cognitive
35 Rosenbaum P. The randomized controlled trial: an excellent design,
therapy for depression: a new approach to preventing relapse.
but can it address the big questions in neurodisability?
New York, NY: The Guilford Press, 2002.
Dev Med Child Neurol 2010; 52: 111.
10 Young JE, Klosko JS, Weishaar ME. Schema therapy: a practitioner’s
36 Campbell M, Fitzpatrick R, Haines A, et al. Framework for design
guide. New York, NY: The Guilford Press, 2003.
and evaluation of complex interventions to improve health.
11 Arch JJ, Eifert GH, Davies C, Plumb Vilardaga JC, Rose RD, BMJ 2000; 321: 694–96.
Craske MG. Randomized clinical trial of cognitive behavioral
37 Cuijpers P, Berking M, Andersson G, Quigley L, Kleiboer A,
therapy (CBT) versus acceptance and commitment therapy (ACT) for
Dobson KS. A meta-analysis of cognitive-behavioural therapy for
mixed anxiety disorders. J Consult Clin Psychol 2012; 80: 750–65.
adult depression, alone and in comparison with other treatments.
12 Bogels SM, Wijts P, Oort FJ, Sallaerts SJ. Can J Psychiatry 2013; 58: 376–85.
Psychodynamic psychotherapy versus cognitive behavior therapy
38 van Tulder MW, Suttorp M, Morton S, Bouter LM, Shekelle P.
for social anxiety disorder: an efficacy and partial effectiveness trial.
Empirical evidence of an association between internal validity and
Depress Anxiety 2014; 31: 363–73.
effect size in randomized controlled trials of low-back pain.
13 Barth J, Munder T, Gerger H, et al. Comparative efficacy of Spine 34: 1685–92.
seven psychotherapeutic interventions for patients with depression:
39 Bradley H, Rucklidge JJ, Mulder RT. A systematic review of trial
a network meta-analysis. PLoS Med 2013; 10: e1001454.
registration and selective outcome reporting in psychotherapy
14 Rosenzweig S. Some implicit common factors in diverse methods randomised controlled trials. Acta Psychiatr Scand 2017; 135: 65–77.
of psychotherapy. Am J Orthopsychiatry 1936; 6: 412–15.
40 Dragioti E, Dimoliatis I, Fountoulakis KN, Evangelou E.
15 Luborsky L, Rosenthal R, Andrusyna TP, et al. The Dodo Bird A systematic appraisal of allegiance effect in randomized controlled
Verdict is alive and well—mostly. Clin Psychol Sci Pract 2002; 9: 2–12. trials of psychotherapy. Ann Gen Psychiatry 2015; 14: 25.
16 Tolin DF. Is cognitive-behavioral therapy more effective than other 41 Andresen R, Caputi P, Oades LG. Do clinical outcome measures
therapies? A meta-analytic review. Clin Psychol Rev 2010; 30: 710–20. assess consumer-defined recovery? Psychiatry Res 2010;
17 Hofmann SG, Asnaani A, Vonk IJ, Sawyer AT, Fang A. The efficacy 177: 309–17.
of cognitive behavioral therapy: a review of meta-analyses. 42 Webb CA, Derubeis RJ, Barber JP. Therapist adherence/
Cognit Ther Res 2012; 36: 427–40. competence and treatment outcome: a meta-analytic review.
18 Norcross JC. Psychotherapy relationships that work: evidence-based J Consult Clin Psychol 2010; 78: 200–11.
responsiveness. New York, NY: Oxford University Press, 2011.
43 Meier A, McGovern MP, Lambert-Harris C, et al. Adherence and 64 Tyrer P. Personality dysfunction is the cause of recurrent
competence in two manual-guided therapies for co-occurring non-cognitive mental disorder: a testable hypothesis.
substance use and posttraumatic stress disorders: clinician factors Personal Ment Health 2015; 9: 1–7.
and patient outcomes. Am J Drug Alcohol Abuse 2015; 41: 527–34. 65 American Psychological Association. American Psychological
44 Stanley MA, Wilson NL, Amspoker AB, et al. Lay providers can Association policy statement on evidence-based practice in
deliver effective cognitive behavior therapy for older adults with psychology 2005. http://www.apapracticecentral.org/ce/courses/
generalized anxiety disorder: a randomized trial. Depress Anxiety ebpstatement.pdf?_ga=1.8667125.1199545620.1456173557 (accessed
2014; 31: 391–401. Feb 21, 2017).
45 Horvath AO, Symonds BD. Relation between working alliance and 66 Rosen GM, Davison GC. Psychology should list empirically supported
outcome in psychotherapy: a meta-analysis. J Counsel Psychol 1991; principles of change (ESPs) and not credential trademarked therapies
38: 139–49. or other treatment packages. Behav Modif 2003; 27: 300–12.
46 Tschuschke V, Crameri A, Koehler M, et al. The role of therapists’ 67 Lemmens LH, Arntz A, Peeters F, Hollon SD, Roefs A, Huibers MJ.
treatment adherence, professional experience, therapeutic alliance, Clinical effectiveness of cognitive therapy v. interpersonal
and clients’ severity of psychological problems: prediction of treatment psychotherapy for depression: results of a randomized controlled
outcome in eight different psychotherapy approaches. Preliminary trial. Psychol Med 2015; 2: 1–16.
results of a naturalistic study. Psychother Res 2015; 25: 420–34. 68 Jordan J, Carter JD, McIntosh VV, et al. Metacognitive therapy
47 Pfeifer BJ, Strunk DR. A primer on psychotherapy process research: versus cognitive behavioural therapy for depression: a randomized
a review of cognitive therapy of depression. Aust Psychol 2015; pilot study. Aust NZ J Psychiatry 2014; 48: 932–43.
50: 411–15. 69 Ellard KK, Fairholme CP, Boisseau CL, Farchione TJ, Barlow DH.
48 Kivlighan DM, Marmarosh CL, Hilsenroth MJ. Client and therapist Unified protocol for the transdiagnostic treatment of emotional
therapeutic alliance, session evaluation, and client reliable change: disorders: protocol development and initial outcome data.
a moderated actor-partner interdependence model. J Couns Psychol Cogn Behav Pract 2010; 17: 88–101.
2014; 61: 15–23. 70 Jacobson NS, Dobson KS, Truax PA, et al. A component analysis of
49 Bell EC, Marcus DK, Goodlad JK. Are the parts as good as the cognitive-behavioral treatment for depression. J Consult Clin Psychol
whole? A meta-analysis of component treatment studies. 1996; 64: 295–304.
J Consult Clin Psychol 2013; 81: 722–36. 71 Hedman E, Ljotsson B, Lindefors N. Cognitive behavior therapy via
50 Eddy KT, Dutra L, Bradley R, Westen D. A multidimensional the Internet: a systematic review of applications, clinical efficacy
meta-analysis of psychotherapy and pharmacotherapy for and cost-effectiveness. Expert Rev Pharmacoecon Outcomes Res 2012;
obsessive-compulsive disorder. Clin Psychol Rev 2004; 24: 1011–30. 12: 745–64.
51 Hofmann SG, Barlow DH. Evidence-based psychological 72 Cavanagh K, Millings A. (Inter)personal computing: the role of the
interventions and the common factors approach: the beginnings of therapeutic relationship in E-mental health. J Contemp Psychother
a rapprochement? Psychotherapy (Chic) 2014; 51: 510–13. 2013; 43: 197–206.
52 Egan G. The skilled helper. Pacific Grove, CA: Brooks/Cole, 2002. 73 Vilardaga R, Hayes SC, Levin ME, Muto T. Creating a strategy for
53 Herbert JD, Forman EM. The evolution of cognitive behaviour progress: a contextual behavioral science approach. Behav Analyst
therapy: the rise of psychological acceptance and mindfulness. 2009; 32: 105–33.
In: Herbert JD, Forman EM, eds. Acceptance and mindfulness in 74 Hogue A, Ozechowski TJ, Robbins MS, Waldron HB. Making
cognitive behaviour therapy: understanding and applying the new fidelity an intramural game: localizing quality assurance procedures
therapies. New York, NY: Wiley and Sons, 2011: 3–25. to promote sustainability of evidence-based practices in usual care.
54 Tolin DF, Diefenbach GJ, Gilliam CM. Stepped care versus standard Clin Psychol Sci Pract 2013; 20: 60–77.
cognitive-behavioral therapy for obsessive-compulsive disorder: 75 Beidas RS, Kendall PC. Training therapists in evidence-based
a preliminary study of efficacy and costs. Depress Anxiety 2011; practice: a critical review of studies from a systems-contextual
28: 314–23. perspective. Clin Psychol 2010; 17: 1–30.
55 Wetherell JL, Petkus AJ, Alonso-Fernandez M, Bower ES, 76 Leitan ND, Murray G. The mind-body relationship in
Steiner AR, Afari N. Age moderates response to acceptance and psychotherapy: grounded cognition as an explanatory framework.
commitment therapy vs. cognitive behavioral therapy for chronic Front Psychol 2014; 5: 472.
pain. Int J Geriatr Psychiatry 2016; 31: 302–08. 77 Fuchs T, Schlimme JE. Embodiment and psychopathology:
56 Barrett PM, Dadds MR, Rapee RM. Family treatment of childhood a phenomenological perspective. Curr Opin Psychiatry 2009;
anxiety: a controlled trial. J Consult Clin Psychol 1996; 64: 333–42. 22: 570–75.
57 Stark KD, Streusand W, Krumholz LS, Patel P. Cognitive behavioural 78 Lane RD, Ryan L, Nadel L, Greenberg L. Memory reconsolidation,
therapy for depression: the ACTION treatment program for girls. emotional arousal, and the process of change in psychotherapy:
In: Weisz JR, Kazdin AE, eds. Evidence-based psychotherapies for new insights from brain science. Behav Brain Sci 2015; 38: e1.
children and adolescents. New York, NY: Guilford Press, 2010: 93–109. 79 Ecker B, Ticic R, Hulley L. A primer on memory reconsolidation
58 Davidson PR, Parker KCH. Eye movement desensitization and and its psychotherapeutic use as a core process of profound change.
reprocessing (emdr): a meta-analysis. J Consult Clin Psychol 2001; Neuropsychotherapist 2013; 1: 82–99.
69: 305–16. 80 Fournier JC, Price RB. Psychotherapy and neuroimaging.
59 Lee CW, Cuijpers P. A meta-analysis of the contribution of eye Focus 2014; 12: 290–8.
movements in processing emotional memories. 81 Goldin PR, Ziv M, Jazaieri H, Weeks J, Heimberg RG, Gross JJ.
J Behav Ther Exp Psychiatry 2013; 44: 231–9. Impact of cognitive-behavioral therapy for social anxiety disorder on
60 Barlow DH, Bullis JR, Comer JS, Ametaj AA. Evidence-based the neural bases of emotional reactivity to and regulation of social
psychological treatments: an update and a way forward. evaluation. Behav Res Ther 2014; 62: 97–106.
Annu Rev Clin Psychol 2013; 9: 1–27. 82 Miller WR, Yahne CE, Moyers TB, Martinez J, Pirritano M.
61 Queen AH, Barlow DH, Ehrenreich-May J. The trajectories of A randomized trial of methods to help clinicians learn motivational
adolescent anxiety and depressive symptoms over the course of a interviewing. J Consult Clin Psychol 2004; 72: 1050–62.
transdiagnostic treatment. J Anxiety Disord 2014; 28: 511–21. 83 Layard R, Clark DM. Thrive: the power of evidence-based
62 Wilamowska ZA, Thompson-Hollands J, Fairholme CP, Ellard KK, psychological therapies. London: Allen Lane, Penguin Group, 2014.
Farchione TJ, Barlow DH. Conceptual background, development, 84 Chan SW, Adams M. Service use, drop-out rate and clinical
and preliminary data from the unified protocol for transdiagnostic outcomes: a comparison between high and low intensity treatments
treatment of emotional disorders. Depress Anxiety 2010; 27: 882–90. in an IAPT service. Behav Cogn Psychother 2014; 42: 747–59.
63 Brown TA, Barlow DH. A proposal for a dimensional classification 85 Cuijpers P. Are all psychotherapies equally effective in the
system based on the shared features of the DSM-IV anxiety and treatment of adult depression? The lack of statistical power of
mood disorders: implications for assessment and treatment. comparative outcome studies. Evid Based Ment Health 2016;
Psychol Assess 2009; 21: 256–71. 19: 39–42.