2 Common and Specific Factors of Change

“We must accept finite disappointment, but never lose infinite hope.” – Martin Luther King, Jr

Introduction

People come to counselling for two main reasons: for support and for psychological change. While both these aims are important, they require a different application of skills. Providing support for counselling clients involves a range of processes and actions such as, listening deeply to individuals’ concerns, providing emotional support, psychoeducation, and offering links with wider community services. Many people have not had the chance to receive proper support in their existing relationships. As a result, being empathically heard and understood by a therapist during therapy may be the first time they experience this. The opportunity to tell one’s story and for it to be received compassionately is, in itself, a profoundly healing experience. However, as well as emotional support, clients often are seeking significant changes in their life. This change may be external in terms of their living situation, work environment, or in their relationships. As well as external change, clients often seek internal change. People commonly come to counselling with the realisation that something about themselves needs to change. This usually involves a shift in their self-perspective or insight into life patterns that are not life-giving. The task for the therapist is to know how best to effectively support people in their life circumstances and to help facilitate personal change when it is sought.

Therapeutic Change

How do people change? This is the proverbial 64-million-dollar question. The short answer is, in lots of ways. Just as people are complex, so too is the change process. Multiple disciplines have sought to answer this question and as a result we have a great deal of understanding about the change process. Of course, understanding many aspects of the change process doesn’t mean we always apply our knowledge effectively in the moment, but it does mean we have a solid base from which to embark on a change journey with our clients.

Academic research and theorising about the change process has resulted in the development of a wide range of psychological theories about human functioning. The twentieth century, in particular, saw the development of many theories that purport to provide a map of the change process. As these theories were being developed and applied, therapists tended to prefer certain theories over others. Hence, some therapists would describe themselves as either psychoanalysts, behaviourists, humanists, or social constructionists, among others. Therapists tended to be quite committed to their preferred theory often thinking that it was objectively the best explanation of human functioning and therefore of the psychological change process. This meant that where two people with essentially the same presenting problem sought help – one consulting a psychanalyst for example, and the other a behaviourist – it was likely that both practitioners would espouse the superior benefits of their own psychological theory. This commitment to a particular theory over others tended to result in turf wars and relative claims about the effectiveness of different approaches.

Interestingly, as research into psychotherapy progressed, by the late-middle twentieth century a curious phenomenon was observed by many researchers and practitioners. When research on psychological conditions, was conducted, (e.g. depression), researchers noticed that studies comparing the application of different theories to depressed clients often resulted in similar outcomes. Hence, a cohort of depressed people in a study applying cognitive behavioural therapy, gained similar outcomes as studies applying psychodynamic therapy. At first this was confusing as these therapies looked quite different in their respective strategies and processes. How could such different approaches result in similar outcomes?

Common Factors

As more and more similar findings emerged, researchers proposed that there must be elements of these different therapies that were common among them. While there were many differences between therapies, maybe there were more commonalities than was first thought. This proposition spurred research into these potential ‘common factors’ of therapeutic change. Common factors research has now existed for over forty years and many factors common to the change process have been identified. The list of common factors is itemised slightly differently depending on the particular study. One early and influential writer, Jerome Frank (1963/1993) identified four essential common factors of effective psychotherapies:

1. an emotionally charged confiding relationship with a helping person;
2. a healing setting;
3. a rationale, conceptual scheme, or myth that provides a plausible explanation for the client’s symptoms and prescribes a ritual or procedure for resolving them; and
4. a ritual or procedure that requires the active participation of both client and therapist and that is believed by both to be the means of restoring the client’s health (pp. 40–43).

Another influential study by Michael Lambert (1992) also identified four similar common factors. These were:

1. extratherapeutic factors (or client factors);
2. the therapeutic relationship;
3. theory/technique;
4. hope and expectancy.

The recognition of the influence of common factors in therapeutic change was well captured in the humorous statement attributed to the dodo bird in Alice in Wonderland who said, “Everybody has won and all must have prizes”. In other words, all bona fide theories, well applied, produce similar outcomes. While there is strong evidence for what is referred to as the ‘Dodo Bird Effect’, there remains unanswered questions regarding specific mechanisms of change whether they be more detailed aspects of recognised common factors or whether they are more specific in nature beyond what is common. In reality there are many common factors and these can be grouped in a variety of ways. Whether some of these factors are more efficacious when applied to specific presenting conditions or not is still under investigation. One study which sought to group an expanded collection of common factors into categories was conducted by Grencavage and Norcross (1990). They identified eight-nine common factors and grouped them into five categories:

• patient characteristics (e.g., positive expectations/hope, actively seeking help)
• therapist qualities (e.g., enhancing hope, empathic understanding)
• change processes (e.g., catharsis, the acquisition and practice of new behaviors)
• treatment structure (e.g., use of techniques or rituals and a healing setting)
• relationship elements (e.g., development of the alliance) (Grencavage & Norcross, 1990, p. 374; Eubanks & Babl, 2024).

As the field of psychotherapy has sought to further understand the mechanisms of psychological change, these and other factors continue to be studied in depth. Hence, there have been a range of studies exploring what characteristics clients bring to therapy (Bohart & Tallman, 2000; Fuertes, 2022; Gelso & Kline, 2022; Holdsworth et al., 2014). The nature of the therapeutic relationship has been studied from many perspectives providing strong evidence that it is one of the most influential factors in the change process (Borden, 1979; Gelso, 2011, 2022; Horvath, 2009). While theory has been recognised as being less influential than was previously thought, it still is an important factor. New and existing theories continue to be developed, often with a focus on a particular population or set of conditions. Finally, as noted by Frank as early as the 1960s, hope for change is an influential factor and continues to be studied to better understand its effects in the change process (Larsen & Stege, 2010; O’Hara, 2013; Synder, 2002).

Specific Factors

While there is evidence for the action of common factors of therapeutic change, there remains debate as to whether certain presenting conditions require more than the application of common mechanisms of change. This view is conceptualised in two mains ways. The first is that certain conditions need a greater focus and application of existing common factors than others. For example, there is evidence that some presenting problems rely less on the therapeutic relationship than others (Zilcha-Mano et al., 2019). One could certainly imagine that for some practical problems encountered by mature and well-adjusted individuals the relationship factor is less so than for others who are less certain about themselves and who have encountered more traumatic experiences. The second way of conceptualising specific factors is to argue that the more dysfunctional the presenting problem, the greater the need for highly targeted interventions. An example of such a presentation is personality disorders. While therapists working with people who struggle with challenging symptoms, such as dissociation, high levels of emotional reactivity, and cognitive distortions, will certainly employ the common factors of change, they will also employ strategies that are highly specific to the situation, such as metabolised countertransference, behavioural activation or memory reconsolidation.

Common and specific factors have largely been considered as separate in nature and this has certainly been evident in the research. However, recently, there is recognition that rather than conceptualising these factors as separate, it is more useful and accurate to consider them to be mutually interacting. This makes intuitive sense as each person coming to therapy brings their own unique set of strengths and limitations and each presenting problem is experienced by people uniquely, requiring a tailored approach to meet each respective need (de Felice et al., 2019).

Principles of Change

Another variation on key mechanisms of change is that proposed by Goldfried (1980, 2019). In an attempt to acknowledge the common factors and specific factors, Goldfried proposed what might be regarded as a higher-order level of change in terms of principles of change. He proposed the following five common principles:

• fostering the patient’s hope, positive expectations, and motivation;
• facilitating the therapeutic alliance;
• increasing the patient’s awareness and insight (e.g., awareness of connections between thoughts, feelings, needs, actions);
• encouraging corrective experiences (i.e., encouraging patients to take risks and engage in new behaviors that lead to a shift in cognitions and emotions);
• emphasizing ongoing reality testing (i.e., helping patients to process corrective experiences and consolidate positive changes by recalibrating their expectations and self-views to be in line with their new reality).

The idea here is that no matter the therapeutic approach being employed, change will be dependent on the application of the above principles. How these principles may be applied will vary but that they are applied is essential to the change process.

The Importance of Hope

One of the recurring common factors is hope. The significance of hope is understandable, for without hope and an expectation that one’s problem can either be resolved or improved, there would seem little benefit in seeking help. So, there is generally strong agreement that hope is an important factor in healing and change. One of the difficulties, though, with hope is that it is not always an easy concept or experience to grasp. What do we even mean by hope and what does it look like? This question takes on further significance when we consider not just individual differences but also cultural differences. Is the concept of hope a transcultural concept or is it considered differently in different cultures? It is beyond the scope of this book to explore this question in detail although it is worthy of note that in recent years hope has been the subject of cross-cultural research finding both transcultural features and unique cultural perspectives (Himmelberger et al., 2022; Zhang et al., 2023).

One comprehensive definition of hope is provided by Dufault and Martocchio (1985) who define hope as ‘a multidimensional lifeforce characterized by a confident yet uncertain expectation of achieving a future good which, to the hoping person, is realistically possible and personally significant’ (p. 380). In this definition we see that hope is an energy or lifeforce that moves us towards a future good. When we feel confused or depressed it is difficult to see the future in a positive light and a lack of a hopeful outlook tends to decrease our energy. It might be understood that this energy forms part of what in other contexts is referred to as personal agency. Agency is the belief that we have power to influence our life and the world around us.

Researchers have identified at least three different forms or types of hope. Nursing researchers have proposed two forms of hope: generalised hope and particularised hope. Similarly, psychology researchers identify two forms of hope referred to as basic hope and goals focused hope (Trzebiński & Zięba, 2004; Synder 2002). Generalised or basic hope is that foundational belief in the importance of trust in self, others, and the world. This is not a naïve trust but one gained through affirmative experiences leaving one with a positive view of life in which exploration and appropriate risk-taking are supported. Particularised hope is a goal-focused hope in which future goals are set and pursued. According to Synder, goal focused hope involves setting clear goals, developing a range of routes or pathways towards these goals and also having motivation to achieve the goals. If any one of these three elements is missing, hope is limited. Sometimes our goals are blocked or at least are very difficult to achieve and at such times a basic or generalised hope provides comfort and a foundation for ongoing risk and exploration. Synder (2000) found that high-hope people have better mental health, have an ability to find a breadth of routes towards their goals, and tend to be more resilient when goal achievement is blocked.

O’Hara and O’Hara (2021) have proposed a third type of hope which they call transformative hope. Sometimes even though we have a solid psychological foundation of trust and therefore a positive life view, we can find our goals unattainable for reasons beyond ourselves or find ourselves in circumstances beyond our ability to directly control. In such situations it may not be the goals that have to be changed or the situation or circumstances but ourselves. In other words, sometimes our hope is founded on an inner change. This change may be found in a new way of relating to the insurmountable problem or a new way of seeing ourselves.

Implications for Practice

We believe that common and specific factors of therapeutic change should be considered as being mutually supportive and complementary. It is helpful to think of common factors as the bedrock of effective counselling practice to which we may add specific strategies depending on the need. Having said that, before we can consider the application of a particular therapeutic strategy, we must first join with the client to effectively hear their story and establish a solid therapeutic relationship. The following is a brief overview of key things to consider, especially in the early phases of therapy.

Establishing a Collaborative Stance

A collaborative stance is essentially the view that therapy is about the client and not the therapist, or clever psychological theories. It is quite a risk for a person to come to therapy as they don’t know us and don’t really know if we are going to be able to help them. It behoves us to respect the trust they place in us. We are more likely to be of service to our clients when we seek to join with them in a relational journey of exploration. While we as therapists have certain expertise, the client also has expertise in their own lives. If we approach clients with this recognition and respect for who they are and what they bring to therapy, we will possess an attitude of collaboration. A collaborative stance is evidenced in deep listening, joint problem definition and case formulation, and in empowering the other.

Facilitative Interpersonal Skills

Facilitative interpersonal skills (FIS) are those skills that therapists have and apply in establishing and maintaining the therapeutic relationship. They are considered to be different from general social skills although overlapping. A key difference between social skills and FIS is that those with FIS are able to apply interpersonal skills in the immediate moments of therapy in an effective manner. FIS include the skills of verbal fluency, emotional expression, persuasiveness, hopefulness/positive expectation, warmth/acceptance/understanding, empathy, alliance-bond capacity, and alliance rupture repair responsiveness (Anderson, et al., 2019). A focus on FIS developed out of the concept of common factors with an expectation that therapists with greater FIS would be more able to develop and maintain a therapeutic relationship with clients and as such provide increased therapeutic outcomes. It is thought that FIS is a transtheoretical factor and as such contributes to better outcomes no matter the counselling theory being employed. Several studies have provided support for this view, demonstrating that therapists with high levels of FIS do tend to provide increased therapeutic outcomes (Anderson et al., 2016; Schöttke et al., 2017).

The research on FIS affirms the importance of developing FIS in counsellor training and throughout one’s career. Considering the importance of FIS in achieving effective client outcomes, therapists—whether in training or already practising—would benefit from reviewing and refining their mastery of these skills.

Client Factors

Another issue to consider when working with people is what the individual, couple or group bring to therapy. People are a mix of natural strengths and limitations, and these can be evidenced in many forms. The following list is a sample of qualities that clients bring to therapy:

• Readiness for change
• Personality and attachment style
• Coping style
• Attitude towards therapy
• Culture
• Resilience
• Expectation
• Psychological mindedness
• Demographic characteristics (Cooper, 2008; Duncan et al., 2022)

One of our essential tasks as therapists is to pay close attention to these various client factors because we know that as we work with client strengths and limitations, the outcomes of therapy are likely to be more effective.