Review

Common versus specific factors in psychotherapy: opening

the black box
Roger Mulder, Greg Murray, Julia Rucklidge

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

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 Review
Panel 1: Examples of specific psychological interventions
Acceptance and commitment therapy3
A psychological intervention that uses acceptance and
mindfulness strategies with commitment and behaviour-change
strategies to increase psychological flexibility. The object of this
therapy is not to eliminate difficult feelings, but rather to accept
what life brings and to move towards valued behaviours.
Cognitive behavioural therapy (CBT)
Focuses on the reciprocal relationships among thinking,
behaviour, and emotions to decrease symptoms and relapse
risk. It focuses on helping clients manage their symptoms by
changing the way they think and behave.
Dialectical behavioural therapy4
A therapy designed specifically to help people change patterns of
behaviour that are not helpful, such as self-harm and suicidal
thinking. The therapy targets increasing emotional and cognitive
regulation by learning about triggers that lead to specific states,
as well as assessing which coping skills to apply to a sequence of
events, all conducted within a validating environment created by
the therapist. This therapy combines CBT techniques alongside
distress tolerance, acceptance, and mindfulness strategies.
E-therapy
E-therapy uses the power and convenience of the internet to
allow for fully self-guided therapy via an automated programme
or real-time interactions with a therapist. Self-guided automated
therapies rely on the development of apps or programmes, with
responses that are designed on the basis of common features of
presenting problems. The client therefore works their way
through the programme independently, without any human
support, guidance, or feedback. By contrast, online therapy
involves interactions between an individual and a professional,
which can be either simultaneous or time-delayed
communications, to help people resolve psychological and
interpersonal issues. E-therapy interventions can also include
videoconferencing, avatar chats, and the use of email.
Eye movement desensitisation and reprocessing therapy5
A psychotherapy developed to help reprocess disturbing
memories associated with post-traumatic stress disorder. The
therapy uses an eight-phase approach, including recall of
distressing images while receiving several types of bilateral
sensory input (eg, side-to-side eye movement, tones, or taps).
Interpersonal and social rhythm therapy6
An amalgamation of interpersonal therapy addressing losses,
role conflicts, and other interpersonal problems with
behaviours aimed at stabilising circadian rhythms via stabilising
social rhythms (eg, fixing wake time across 7 days of the week).
clear and the treatment is easily manualised, facilitating
CBT becoming the dominant training approach for
psychotherapists worldwide. The ambitious Increased
Access to Psychological Therapies (IAPT) programme,
which provides a stepped care approach in England, has
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Interpersonal psychotherapy
Interpersonal psychotherapy is a brief structured approach
that addresses interpersonal issues and role transitions. It is
based on the principle that there is a relationship between
how people communicate and interact with others and their
mental states.
Mentalisation-based treatment7
A form of psychodynamic psychotherapy that aims to
increase capacity for mentalisation (a process of implicit and
explicit interpretation of the actions of oneself and others as
meaningful and based on intentional mental states) to
improve affect regulation, achieve better behavioural control,
improve interpersonal relationships, and enable better
pursuit of life’s goals.
Metacognitive therapy8
The focus of this psychotherapy is on the role of
metacognitive beliefs that maintain psychological symptoms
such as worry, rumination, and fixation, and how to modify
these metacognitive beliefs that give rise to unhelpful
thinking patterns. Metacognition is the part of cognition that
controls mental processes and thinking.
Mindfulness-based cognitive therapy9
This therapy uses CBT methods alongside mindfulness and
mindfulness meditation, strategies that focus on becoming
aware of all incoming thoughts and feelings and accepting
them without attaching to them or reacting to them. The goal
of mindfulness-based cognitive therapy is to interrupt the
automatic thoughts and teach clients to focus less on reacting
to incoming stimuli and, instead, to accept and observe the
thoughts without judgment.
Schema therapy10
Schema therapy incorporates facets of cognitive therapy,
behaviour therapy, object relations, gestalt therapy, and
mindfulness with a specific focus on working on maladaptive
schemas. Schemas are defined as those core themes and
patterns that repeat throughout life and contribute to poor
coping styles and social dysfunction.
prioritised CBT as the psychotherapy having the most
evidence.24
Second, we know that CBT (as the exemplar evidence-
based psychotherapy) is effective for a range of presenting
problems compared with several different comparators

(eg, waitlist control). However, the existing evidence base
has several limitations, particularly concerns about
researcher allegiance and weak comparators (including
the possible detrimental or nocebo effects of waitlist
control conditions25). Some evidence suggests that the
effects of CBT for depression are decreasing significantly
with time,26 which could reflect decreased researcher
allegiance, improved treatment as usual, diminution of
positive expectancy effects for CBT, and other factors.
Third, because little attention has been paid to
psychotherapy processes, we know little about how
psychotherapies work, for whom they work, and under
what circumstances they work. Further, little is known
about how treatments designed for specific disorders
translate into the real world where comorbidity is the rule
rather than the exception. Not surprisingly, this knowledge
gap has engendered a split between psychotherapy
researchers and psychotherapy prac­titioners.27
The final consequence (and the focus of this Review) is
that—in the absence of process-focused studies—whether
CBT and similar therapies work through common factors
or the key features of a healing encounter,28 rather than the
specific factors postulated by their adherents, remains
unclear. Even the American Psychological Association has
polarised sub­ groups; Clinical Psychology Division 12
originally elevated techniques as primary when it
developed a list of empirically supported treatments,
whereas Psychotherapy Division 29 prioritises the
therapeutic relationship.29 The argument can be traced
back to an historic debate between Carl Rogers and
B F Skinner,30 with Rogers proposing that an accepting and
genuine relationship with the therapist was necessary and
sufficient to release a natural human tendency towards
growth, and Skinner highlighting specific learning
procedures that might be part of the change process.
Ongoing heat in the debate centres on evidence-based
practice in psychotherapy, and the proponents of specific
factors are sensitive to the possibility that clinicians could
reject evidence-based practice altogether on the limited
evidence for specificity of effects—“if the brands don’t
differ, I can do what I want”.27
In summary, an important feature of the existing
psychotherapy literature is that, although long lists can
be compiled of therapeutic brands that have proven
efficacious (and in some cases effective) for particular
problems or diagnoses, it is incorrect to infer that any
psychological therapies have been definitively validated.
As with other constructs, validation of a psychotherapy
would require evidence not only that the approach is
beneficial as expected, but also that the benefits arise
through the mechanisms postulated by the approach and
in the behaviours enacted by therapists. Even within the
CBT tradition, there is unresolved debate over whether
the increasingly popular third-wave therapies such as
acceptance and commitment therapy or metacognitive
therapy are in fact distinct from the flagship cognitive
therapy.31
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Review
Panel 2: The common factor model
• An emotionally charged bond between the therapist
and patient
• A confiding healing setting in which therapy takes place
• A therapist who provides a psychologically derived and
culturally embedded explanation for emotional distress
• An explanation that is adaptive and is accepted by
the patient
• A set of procedures or rituals engaged by the patient and
therapist that leads the patient to enact something that is
positive, helpful, or adaptive
Description of the common factor model adapted from Laska and colleagues19
Paradigmatic differences
From one perspective, the specific factor and common
factors approaches are incommensurable, because they
align with different paradigms. Randomised controlled
trials have generally been done in discrete diagnostic
groups, consistent with the medical model assumption
that the target of treatment is disorders. This approach
contrasts with the humanistic emphasis of the common
factors approach, which assumes that improvement
in individual wellbeing is the ultimate goal. There
are also philosophical differences: the CBT tradition is
strongly positivist, with an ontological assumption that
an individual’s conscious thoughts and schemas are
filters through which reality can be understood more or
less accurately. Psychotherapy based on common factors
(and some eastern-informed third-wave psychotherapies)
adopts a much more constructivist world view.32
Limitations of the existing evidence base
Proponents of specific factors have tended to elevate
randomised controlled trials. The limitations of these
trials as a source of information about psychological (or
pharmacological) treatments are well recognised.33 First,
randomised controlled trials prioritise internal validity
over external validity, generating translational challenges.
Trials typically enrol study populations that are un­
representative of people attending for treatment in
clinical environments, and often their findings are not
generalisable across different ethnicities and cultures.34,35
Second, the intervention tested differs substantially from
how it might be provided in other contexts: therapists are
trained in manuals tailored to the study’s population,
typically monitored for compliance, and often employed
by a research group with an allegiance to the positive
outcomes for their brand.36 Further, the underlying logic
of a randomised controlled trial—controlled experimental
comparison of a single active ingredient with its
absence—extends poorly to psychological interventions.
The intervention received by an individual will depend
on their behaviour during therapy, and psychological
factors in response to the intervention are not placebo
 Review
but putative active ingredients. Interventions are complex
multicomponent activities, and therapies are typically
based on an individually tailored case formulation (at a
minimum, weighting of different components of a
manualised intervention to the needs of the case).23
Additionally, the dissemination of findings leads to
further bias. Negative trials are less likely to be reported,
thereby inflating effect sizes.37 Low-quality studies often
result in larger effect sizes.38 Trial registration is poor, so
we cannot know whether outcomes are selectively
reported, particularly by groups with a strong allegiance
to the treatments. Findings from a 2017 systematic
review39 showed that only 12% of psychotherapy trials
were prospectively registered with clearly defined primary
outcome measures.
One obvious approach to the dodo bird problem is to test
whether different therapies do lead to different outcomes.
Head-to-head comparisons generally suggest small
differential effects, which are smaller and non-significant
after researcher allegiance is controlled for.40 However, this
literature has substantial limitations. Most studies have
investigated cognitive therapy or CBT as one of the
treatment groups, so specific strengths of other approaches
are poorly understood. Only a narrow range of treatment
outcome measures have been systematically examined,
most typically acute symptom reduction; longer-term
effects, including relapse prevention measures for
common chronic conditions, might differentiate some
therapies for some problems. Differences might be
revealed if a wider range of treatment outcome measures
were used, including functioning, quality of life, and
individualised measures of treatment outcome.41 However,
such trials are expensive and rarely undertaken.
Differences might also be larger if moderating factors such
as individual differences between patients were accounted
for in outcome modelling.
Another way to test the specific factor model is through
therapist adherence. Improved adherence to theory-
specified factors in evidence-supported therapies should
improve patient outcomes, if these specific factors are
important to the success of the therapy. However, the
evidence has not generally supported this hypothesis, with
findings from a meta-analysis42 showing that neither
variability in competence nor adherence was related to
patient outcome, suggesting that these variables are
relatively inert therapeutic agents. The broader literature is
split on this question, with some investigators finding no
effect of treatment integrity on outcomes, some a positive
effect, and some a negative effect (potentially due to an
overly rigid application of technique, which could be
detrimental to the therapeutic alliance for some clients).43
Extent of training might also not be relevant to outcome, as
suggested by the work of Stanley and colleagues.44 Indeed,
therapeutic alliance, a common factor, might be a more
important variable to instigate change than therapeutic
adherence, although even these effect sizes are modest
(mean alliance–outcome correlation 0·26).45 There are
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corresponding problems with the alliance literature, in
which measured alliance might in fact be a consequence
rather than a cause of improved outcomes. Little research
has been specifically designed to parse out alliance effects.
The relationship between treatment adherence and the
therapeutic alliance was positive in some studies and
negative in others,46 highlighting the complexity in
identifying the variables essential for positive outcomes.
Regardless, common factor researchers argue that
outcome studies do not answer the most important
outstanding question in psychotherapy—namely, what
are the mechanisms of change? Although the importance
of specific factors has been estimated from effect sizes
of targeted therapies compared with plausible controls,
the importance of common factors has been estimated
correlationally through the association between therapy
outcomes and patient reports of rapport and engagement.
Although the effect sizes of targeted therapies compared
with controls permit causal correlations, correlation
between therapy outcomes and patient engagement
does not, and will be confounded by an overlap between
the success of therapy and the client’s satisfaction with
the therapist.47 Therapeutic alliance is fundamentally
dyadic (ie, a reciprocal working relationship), which sits
uncomfortably with the more medical notion of patient
as recipient of the therapist’s activities.48
Finally, psychotherapy research is difficult and
expensive to conduct, and—without the commercial
investment that occurs in pharmacotherapy research—
deficits of the existing evidence base are attributable
simply to the low power and small number of studies.49
For example, although the effectiveness of behavioural
therapy for obsessive compulsive disorder is similar
to that of pharmacological treatment, investigators of a
meta-analysis50 of psychotherapy and pharmacotherapy
for obsessive compulsive disorder found 15 psychotherapy
trials with a total 705 patients, by contrast with
32 pharmacotherapy trials with a total of 3588 patients.50
A false dichotomy?
The common factor and specific factor positions might be
less divergent than they at first appear. First, most specific
factor theorists concede that common factors are
important.51 They argue that their model allows for the
existence of therapist effects, allegiance effects, and other
common factors. Psychotherapy training programmes
that prioritise CBT interventions for clinical problems, for
example, typically commence with substantial training
in so-called counselling skills, emphasising common
factors such as engagement, optimism, positive regard,
explicit collaboration, and structured goal setting.52
Similarly, at the level of published treatment manuals,
CBT has a strong focus on therapy process and tailoring
of the intervention to the particular client across time.53
Second, common factor theorists seem to be increasingly
tightening their definition of bona fide therapy. They
suggest that the treatments must be delivered by trained

therapists, based on psychological principles, and credible
to the patients receiving them.20
Third, most common factor theorists concede that
some specific techniques are more effective than others
for particular conditions. A major concession is that
exposure-based procedures could be necessary for some
types of anxiety disorders,51 although how exposure is
performed might not matter.54 Both camps acknowledge
that moderator factors, such as age, could be important;
for example, acceptance and commitment therapy is
better than CBT in older adults (≥65 years) with chronic
pain, perhaps because the therapeutic focus was more
aligned with learning to live well with pain, rather than
the treatment being expected to reduce the pain.55
Parental involvement seems to improve and maintain
treatment outcomes for children with anxiety compared
with individualised CBT alone,56 and this effect might be
specific to anxiety disorders.57 Additional parental
involvement does not seem to be necessary for the
treatment of depression in girls.57 Whether the bilateral
eye movements, tones, or taps of eye movement
desensitisation and reprocessing therapy are necessary
components for a trauma to be processed is up for
debate,58 although proponents of this therapy believe
that it is more rapid and can be more effective than
trauma-focused CBT.5,59 Other examples for which there
is broad agreement for problem-specific effects include
treatments for severe motor tics or cognitive deficits in
schizophrenia.60
Fourth, new conceptions of psychopathology such as
the recognition of the overlap between anxiety and
depression,61 the move away from discrete categories to
underlying dimensions,62,63 and the increased importance
of personality variables64 have encouraged the testing
of transdiagnostic treatments based on attention to
mechanisms of change across classes of disorders.
Indeed, emerging from the behavioural tradition, the
so-called third wave or contextual psychotherapies (eg,
acceptance and commitment therapy, mindfulness-based
cognitive therapy, and dialectical behaviour therapy;
panel 1) are less compatible with illness categories and
medical terminology than treatments such as CBT, and
hint that therapeutic change occurs not through a
mechanistic alteration of problematic cognition and
behaviour, but through a more systemic and experiential
healing encounter.32
Finally, proponents of common factors and those of
specific factors arguably subscribe to a similar approach to
evidence-based practice in psychotherapy. The influential
American Psychological Association model of evidence-
based practice (figure 1)65 seems to offer a rapprochement
between specific factors (which are the primary focus
of empirical evidence) and common factors (the
contextualised, agentic client interacting with an expert
clinician). We have added a process dimension to the three
conceptual areas of evidence-based practice (figure 1); at
the level of the individual therapeutic encounter, common
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Review
Best available evidence
Clinican expertise
Client characteristics,
culture, preferences
Process:
Collaborative decision making
Individual case formulation
Ongoing monitoring
Feeding back into research
Figure 1: Evidence-based practice
Production of this figure was based on the the American Psychological
Association policy statement on evidence-based practice in psychology.65
ground is seen in evidence-based psychotherapy as
collaborative, goal-oriented, and reflexive.
The tension between common and specific factors might
be best reframed as a question—what are the general
principles of therapeutic change?66 This strategy would
help to solve the problem of a burgeoning list of similar,
multicomponent, branded interventions for a bewildering
array of poorly validated, discrete conditions. For example,
the existing therapy outcome data suggest equivalence of
CBT, interpersonal therapy, and meta­cognitive therapy for
depression.67,68
Future directions
Overview
As we hope has been demonstrated, there is insufficient
evidence to resolve the debate between common and
specific factors in psychotherapy. The debate has been
more influenced by power battles and paradigms than
thorough empirical evaluation. The dominance of CBT,
with its strong attachment to biomedical models of
psychopathology (reflected in its use of symptom
measures and randomised controlled trials), has been
criticised by some researchers as evaluating the wrong
questions about psychotherapy. The common factor
model, however, has been described as supporting an
anything-goes approach, thereby undermining the very
factors that make psychotherapy effective.
What can be done to move the field forward? First, it
needs to be recognised that psychotherapy has come a
long way. The introduction of rigour in psychotherapy
 Review
practice and training has improved the quality of service
provision and patient outcomes, and the implementation
of the principles of evidence-based practice has enhanced
the effectiveness of treatment and has almost certainly
reduced harm. The pragmatic importance of structured
psychotherapies having been extensively investigated
and found safe should not be underestimated. The
controversy remains centred on the extent to which
psychotherapies have correctly identified whether their
specified components are responsible for the therapeutic
change, rather than challenging the usefulness of an
evidence-based approach.
Although common factors are important in all
psychotherapies, simply taking this approach alone is
unlikely to lead to useful models for clinical practice.
There are virtually no experimental studies to support the
hypothesis that common factors are sufficient to effect
change. There is no well argued theory that accounts for
treatment outcome, let alone evidence about such a theory.
Neither espousal of common factors nor continued head-
to-head comparative studies of different psychotherapies
seems a satisfactory way to move the field forward.
Arguably, the debate over common versus specific factors
is a distraction from the urgent need to better understand
the mechanisms of action of psychological treatments.
We suggest that there are at least four approaches
which might be useful in the future. The first is the
transdiagnostic treatment approach. The second is to
develop component (ie, dismantling or additive) studies
to identify whether specific active ingredients contribute
to differential outcomes. The third involves considering
the implications of e-therapies, and the fourth is an
aspirational call for a thoroughgoing clinical science.
Transdiagnostic treatments
The transdiagnostic treatment approach highlights the
common factors in emotional disorders and uses unified
protocols instead of developing different treatment
protocols for each emotional disorder.69 This treatment
includes specific approaches that are believed to transcend
diagnostic categories, including emotional regulation
components, cognitive reappraisal, and emotional aware­
ness training.62 The unified protocol has demonstrated
effectiveness in various disorders, including generalised
anxiety, panic and agoraphobia, social anxiety, and major
depressive disorder.69 This approach demonstrates that the
process of learning to regulate emotions and modify
negative emotional experience can be construed as
an alternative common mechanism of change during
therapy.31 These transdiagnostic treatments often use
group therapies, allowing large sample sizes to test for
mechanisms of change.
Psychotherapy component studies
Component studies (dismantling or additive) identify
whether and in what circumstances specific active
ingredients contribute to differential outcomes. In
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dismantling designs, the full treatment is compared with
the treatment with at least one element removed; in
additive designs, a component is added to an existing
treatment to assess whether the addition improves
outcome. In a classic dismantling study, Jacobsen and
colleagues70 showed that behavioural activation alone was
as effective as full CBT for depression; this work was
pivotal in bringing attention to therapeutic mechanisms.
Findings from a meta-analysis49 of component treatment
studies showed that, for dismantling studies, there were
no significant differences between the full treatment and
the dismantled treatment. However, the investigators
reported that treatments with an additive component
yielded a small but significant positive effect at completion
(d=0·14) and a slightly larger effect at follow-up (d=0·28).
This result was only for specific problems that were targets
for treatment. These findings suggest that a strategy
that starts with effective treatments and tests which
components incrementally improve outcomes could be a
useful method to advance the development of psycho­
therapies. However, researcher allegiance to the added
component might also explain some of the discrepancy
between additive and dismantling designs.49 Such studies
might be consistent with stepped care approaches in
terms of determining the minimal amount of therapeutic
input necessary to effect the largest amount of change in
symptoms, allowing services to offer more cost-effective
treatments.
E-therapies
At present, online therapies range from fully self-guided
approaches to real-time interactions with a therapist
via the internet, with most internet research focusing
on low-intensity structured interventions (typically
CBT) delivered with little or no online coaching
support. In a review of more than 100 randomised
controlled trials, Hedman and colleagues71 reported that
internet-delivered CBT produced similar outcomes to
conventional face-to-face CBT for the treatment of
depression, anxiety, female sexual dysfunction, cannabis
use, eating disorders, and pathological gambling. It was
less effective for social anxiety, obsessive compulsive
disorder, and bipolar disorder.
At first glance, this pattern of findings suggests (contrary
to the proponents of both common and specific factors)
that, far from being sufficient, in certain circumstances a
therapeutic relationship might not even be necessary for
efficacy, although it is important to consider that an
e-therapy website offers a symbolic form of relationship.72
Cultural artifacts (books, film, etc) are premised on such
disembodied but nonetheless influential relationships.
Although very different from the traditional image of
a real-time healing encounter, engagement with an
e-therapy website (laden with evidence of benevolent
therapeutic intention) might nonetheless constitute a
meaningful relationship with therapeutic benefits.
Indeed, research into online therapies highlights features

of this symbolic relationship as crucial for engagement
and adherence (eg, demonstration of care, personalised
treatment, and authentic communication).72 Future
research investigating the role of specific and common
factors will therefore need to consider the range of ways in
which a therapeutic relationship can be constructed.
Additionally, consistent with the suggestion to
conduct more dismantling studies, e-therapies offer the
opportunity for sophisticated research to explore whether
any specific components of therapy are necessary for
change to occur. Systematic manipulation of various
putative mechanisms of change—including the presence
or absence of a therapist, specific treatment factors (eg,
type of exposure), specifics of cognitive coping skills to
deal with distressing events or thoughts, and whether
homework is included—could enable clearer elucidation
of the common or specific factors necessary for effective
change. Any component of CBT (including extent, dose,
and timing of therapeutic contact) can easily be
manipulated as part of e-therapy in that modules and
content can be adapted using the programming algorithm.
E-mental health programmes, even ones that are fully
automated, can differ in how much common factors are
emphasised; the voices used, how responsive the
programme is to the data entered by the user, how much
communication is made on hope for improvement, and
how credible the illustrative characters are, can all increase
or decrease the presence of so-called common factors.72
Such controlled dismantling, a strategy that is quite
achievable with e-therapy, could reveal the necessary and
sufficient components for treatment to result in change.
Need for a thoroughgoing clinical science
There are growing calls to integrate psychotherapy
research into broader clinical psychological theories
of pathology, intervention, and health,31,73 and into
translational models recognising the challenges of
dissemination and implementation.74,75 An aspirational
goal for psychotherapy research would be a shift towards
translational science of human change processes
(figure 2). This science would recognise the importance
of developing explicit clinical science frameworks
covering fundamentally different—but interdependent—
types of question.
Psychotherapy research
The broader context
To date, treatment outcome research (ie, whether therapies
work) has been prioritised. Treatment process research
(ie, how therapies work) is clearly lacking, leaving the
dodo bird question alive. However, both of these questions
raise more fundamental issues about pathology (what
needs to change?) and health (why therapies work). These
questions can be conducted both top-down (prioritising
experimental or statistical control) and bottom-up
(emphasising context and translational science issues).
Depending on theorists’ assumptions and values, the
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Review
approach to each of these domains of research, and their
weighting relative to each other, will vary. We propose that
such assumptions are best made explicitly, and best
recognised as social constructions in which empirical
research takes place (figure 2).
An emerging theme in theorising about psychotherapy
is the embodied nature of human beings, counterbalancing
the cognitivism of CBT, and encouraging consideration of
biobehavioural explanations of behaviour change.76,77
For example, Lane and colleagues78 suggest that emotional
arousal (updating of previous emotional memories through
a process of reconsolidation) is the key ingredient of
therapeutic change across a variety of psychotherapies.
Ecker and colleagues79 propose a psycho­therapy integrated
framework centred on the brain’s required steps to induce
schema destabilisation and erasure. Neuroimaging studies
show decreased activity across several regions of the
prefrontal cortex after multiple forms of psychotherapy for
depression.80 Goldin and colleagues81 showed that CBT for
social anxiety disorder produced greater changes in the
neural dynamics of patients than did a waitlist control. As
these investigators pointed out, future research could
investigate how different forms of CBT (eg, individual vs
group CBT) and other clinical interventions affect the
temporal dynamics of brain networks, and how these
therapeutic effects generalise to other disorders. Although
this research is in its infancy, more complex multilevel
models (and consequent investigation of the neurobiological
and psychological changes associated with psychotherapy)
have the potential to elucidate how psychotherapeutic
treatments affect individuals.
Training and clinical practice
The optimal approach to dissemination and implemen­
tation of evidence-based practices in psychotherapy is
Scientific context: explicit theory, philosophical
assumptions, knowledge translation
mechanisms, and training model
Treatment process
research
Basic research into
Treatment outcome determinants of
research distress and
wellbeing
Figure 2: Towards a translational science of human change processes
 Review
unknown.75 While we await better understanding of
interventions, how should training be focused to support
evidence-based practice in the community? One
pragmatic approach might be to continue to train
therapists in CBT, the most robustly supported
psychotherapy approach; as noted above, it is a core
element of the system-wide IAPT approach used in
England. Ambiguous evidence for manual-driven practice
suggests that the primary focus of CBT training should be
on therapeutic principles rather than specific techniques.82
Within this training, increased emphasis could be placed
on common factors such as warmth, hope, empathy, and
alliance, alongside the principles of CBT (ie, that thoughts
are not facts, present focus, incremental change, etc). To
recognise evidence for some therapy-specific effects for
certain disorders, it seems reasonable to augment
training in principles with additional modules focusing
on more specific techniques in different conditions where
Panel 3: Implications for training
At least within bona fide therapies, common factors might be
doing as much of the work as specific techniques. Course
content and trainee selection and assessment should reflect
this complex reality.
Given the possibility that therapies are harmful (at least in
terms of opportunity cost), preference should be given in the
training syllabus to brands that have been more widely studied
and critiqued, while holding in mind that evidence of efficacy
and effectiveness is not equivalent to evidence of validity.
As in other areas of health and medicine, therapists must
tolerate working in the absence of clear supporting
evidence in many cases. In this context, scepticism and
open-mindedness are important intellectual attributes for
the trainee therapist. Hopefulness and optimism are
important emotional attributes for the trainee therapist.
Search strategy and selection criteria
We searched PubMed, PsycINFO, Web of Knowledge, and
Google Scholar for articles published between Jan 1, 2000, and
Jan 1, 2016, with a range of terms including “psychotherapy”,
“common factors”, “specific factors”, “e-therapy”, “treatment
adherence”, “therapeutic alliance”, “evidence-based practice”,
“transdiagnostic psychotherapy”, “psychotherapy
components”, and “psychotherapy neuroscience”. We
restricted the language to English. We selected papers from
the identified publications based on the quality of research.
Within topic areas with multiple studies, we selected recent
meta-analyses and systematic reviews and studies that
described new findings. In less well researched areas, we
selected key papers and new findings. We supplemented the
search with earlier landmark papers as well as suggestions
from the reviewers. These landmark papers included seminal
theoretical papers and relevant professional position papers.
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evidence exists, such as post-traumatic stress disorder or
specific phobias.83 Future research into the dissemination
and implementation of evidence-based psychotherapy
practice could then test the effects on the community
of such a hybrid approach.
However, we should not confuse evidence showing
efficacy or even effectiveness with validation of a given
therapy, and we should train therapists to be sceptical of
the recognised brands. In particular, it is clear that
(within bona fide therapies), relationship factors might
be doing as much of the work as specific techniques, and
trainee suitability should include consideration of such
aptitudes. We should be alert to professional self-interest
and self-interested drivers that tend to overstate the
importance of complex, difficult-to-teach therapeutic
skills (panel 3). It is interesting to note, for example, that
early analyses84 of the IAPT programme suggested no
difference in outcomes between low-intensity and high-
intensity versions of CBT.
We argue that the inclusion of common factors
makes a strong case for increased research focus on
psychotherapy processes and mechanisms. This focus
could still be in the context of evidence-supported
common therapeutic mechanisms, as well as the specific
factors currently emphasised (figure 2).26
Future clinical trials in psychotherapy
Given the consistent small differences in comparative
outcome trials of psychotherapy, it might be timely to
reconsider how this clinical research is best conducted.
The most obvious problem is that, because the differential
effect size is small, clinical trials comparing different
therapies would need to be very large to detect an effect. A
review85 of psychotherapies in adult depression reported
that a trial to detect clinically relevant differences (which
were calculated as d=0·24) would require 548 patients. A
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
each group for follow-up outcomes. Continued design and
conduct of randomised controlled trials that are heavily
underpowered will only reinforce the dodo bird effect. The
future of clinical psychotherapy research might therefore
be in large, pragmatic trials using structures such as
practice research networks. These trials could include
e-therapies, group therapies, and face-to-face therapies.
The psychotherapy initiative in public health services and
managed care could offer a platform to examine the effect
of psychotherapies in large numbers of people in a real
clinical situation.
Conclusion
Common and specific factors in psychotherapy have been
discussed for more than half a century. However, the
debate is less dichotomised than it first appears. There is
some agreement that elements from treatment models
grounded in evidence-based practice, such as trained

therapists, credible psychological principles, and manual­
ised treatments, could contribute to the efficacy and safety
of psychotherapy. There is also agreement that common
factors, such as engagement, optimism, and explicit
collaboration, improve outcome. There might be small
but clinically relevant differences in aspects of specific
factors, but these differences are difficult to detect due to
poorly designed, underpowered trials. The future lies
with trying to understand more clearly the mechanism of
change associated with psychotherapy. This strategy will
require different techniques, including large pragmatic
clinical studies, e-therapies, trans­ diagnostic treatment
approaches, and increased understanding of neuro­
biological changes brought about by psychotherapy.
Contributors
All authors contributed to the conceptualisation and writing of the paper.
Declaration of interests
We declare no competing interests.
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