However much we might think our therapy model is uniquely different from other modalities, it would appear that there are some therapeutic strategies that we all share. In that sense, they are truly transtheoretical. Are these the principles that connect us all as therapists?
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Consensus across the modalities of therapy?
“My fantasy is that one day we might be able to have a working conference directed toward the goal of developing the field of therapy, not toward the advancement of any given school of thought or of any one individual’s career.”
The words are those of Marvin Goldfried, from a paper published in 1980. Almost 45 years on, are we any closer to that vision? Turns out, the answer may just be, ‘yes’.
Goldfried suggested that to find any degree of consensus across different therapy modalities that we look not at the level of theoretical frameworks, nor that of therapeutic techniques. Rather, look between them at the level of what he termed “clinical strategies.” Strategies which, if they were to have an empirical foundation, might be called “principles of change.”
He initially suggested two principles that might qualify: (a) providing the patient/client with new, corrective experiences, and (b) offering the patient/client direct feedback.
Two principles become five
Not long after, Goldfried proposed five key principles of change that he argued were transtheoretical. i.e. common across the modalities:
- Fostering the patient’s hope, positive expectations, and motivation.
- Facilitating the therapeutic alliance.
- Increasing the patient’s awareness and insight.
- Encouraging patients to engage in corrective experiences.
- Emphasizing ongoing reality testing.
It’s one thing to propose a hypothesis. It’s quite another to validate it. The extent to which the principles are present in different modalities, and to which there is agreement that they cut across all contemporary approaches to psychotherapy, has now been tested and the results published in a recent paper.
Testing consensus: are the principles relevant and universal?
To test the proposition the paper’s authors developed a simple questionnaire that outlined the five principles and asked respondents to indicate:
- “the extent to which you agree (or disagree) that the following principles are present in your own (or preferred) approach to psychotherapy.”
- “the extent to which you agree (or disagree) that the following principles cut across all contemporary approaches to psychotherapy.”
Response options (and scores) were: Strongly disagree (1), Disagree (2), Neither agree nor disagree (3), Agree (4), Strongly agree (5). Consensus was considered achieved if 95% confidence intervals of mean agreement scores fell above 4.0 (maximum possible 5.0). The further category of “strong consensus,” was met where 95% confidence intervals of mean agreement scores fell above 4.5.
The survey was open to qualified psychotherapy practitioners, clinical trainees; psychotherapy researchers; and graduate students in fields where psychotherapy is a core component.
Of the 1,198 respondents, most were from North America. Most were clinicians, their average age was 50 and their average clinical/research experience spanned 31 years. For the purposes of the study they were grouped into four broad categories based on their theoretical orientation:
The absence of a humanistic category in the list above seems notable. Alas, without knowing precisely how definitions were arrived at, I’m unable to explain this.
Consensus more or less achieved
While different modalities may have radically different systems of belief about human distress and how it can be alleviated, there was a high degree of consensus between respondents from differing modalities over the presence of the principles of change in their own approaches, and their presumed presence in all contemporary approaches.
Respondents’ assessments of the presence of the principles in their own approaches indicated consensus was reached for each of the five principles. Strong consensus was also indicated for the first three (fostering hope, positive expectations, motivation; facilitating the therapeutic alliance; increasing awareness and insight)
Assessments of the presence of the principles in all contemporary approaches indicated consensus for the first four principles, the exception being emphasizing ongoing reality testing. Strong consensus was indicated for the second principle (facilitating the therapeutic alliance).
There’s a little more to the story. In relation to respondents´ assessments that the principles were present in their own approaches, theoretical orientation was found not to influence the presence or absence of consensus for the first three principles (positive expectations, therapeutic alliance, and insight). For the final two principles, however, (corrective experiences and ongoing reality testing), consensus was not indicated for psychodynamic and experiential psychotherapists.
More in common than we think?
It seems then, albeit with one or two exceptions, that therapists from quite divergent theoretical backgrounds can find consensus on the presence of the five principles of change in their own approaches. In addition, except for emphasising ongoing reality testing, they find consensus on their presence in all contemporary approaches to therapy.
I can certainly identify each principle in operation in my own approach. With different emphases for different clients certainly, but present, nonetheless. Regarding other approaches, I’d be cautious about venturing too strong an opinion, though I feel instinctively there’s likely to be a place for each of the principles within all the main modalities.
This caution perhaps explains the finding that, regarding the applicability of the principles to all approaches, consensus was achieved for only four of the five, and strong consensus for only one. In the words of the authors “this may reflect less knowledge about exactly what is involved in other approaches or more conservative estimates.”
What about you?
Fostering the patients hope, positive expectations and motivation. Facilitating the therapeutic alliance. Increasing the patient’s awareness and insight. Encouraging patients to engage in corrective experiences. Emphasising ongoing reality testing. These are the five principles.
To what extent do they each find a place in your practice? Do you find yourself routinely privileging one or more over others? Is there one you don’t value or could value more? What is it that might lead you to adjust the balance of their use with different clients, or even with the same client as work progresses?
This is an elegantly simple study, yet, one which for me has raised so many questions. What is it that I do behind my therapy room door, with whom, when and why? What is it that you do? What is common to us all, and what is different? What kind of conversation might we have if we were to emerge from the silos we spend so much of our time down and have an exchange about how we work and why?
We might even start one now, below. What are your thoughts on what you’ve read here, and on the place of the five principles in your practice?
Just like you we thrive on feedback.
Please leave your thoughts on what you’ve read in the comments section below.
Deeply methodologically flawed study, although the categories/principles may have some use in the Sisyphean common factors mill. This is nonetheless fabulous bait for any self respecting discussion group to go into an absolute feeding frenzy over.
I guess that as the study is essentially based on a questionnaire survey, we might be wise to limit our expectations of its methodological purity. As to whether it precipitates a feeding frenzy of discussion, we’ll just have to wait and see!