Introduction

When marriage and family therapy (MFT) was establishing itself as a viable profession and unique field, magnetic personalities, exciting demonstrations, and unique therapy models played a key role (Karam et al. 2015; Sprenkle and Blow 2004a). During this time, family therapy training was offered in centers that were known for teaching one model (Karam et al. 2015). For example, Philadelphia Guild Guidance Clinic taught structural family therapy; the MRI Brief Therapy Center taught the MRI model; and the Haley and Madanes Family Therapy Institute taught strategic family therapy. As the MFT field gained recognition and maturity, training programs were situated nearly exclusively within university settings (Karam et al. 2015). With the emergence of the Commission on Accreditation for Marriage and Family Therapy Education (COMAFTE), the focus of training shifted to prioritize grounding students in a systemic perspective and teaching several different MFT models (Karam et al. 2015). Despite these changes, the MFT field continued to teach many models in a way that emphasized differences over similarities (Karam et al. 2015; Sprenkle and Blow 2004a, b; Sprenkle et al. 2009). Continuing to emphasize differences encourages students to choose their favorite model at the expense of presenting models as overlapping in concepts and skills (Karam et al. 2015; see also Cornille et al. 2003). Students invest a great amount of effort and thought attempting to determine which model fits them best, which may result in emphasizing depth over breath (Karam et al. 2015). As a variety of models continue to be taught and most practitioners report integrating theories (Perkins 2010; Bradley et al. 2010), perhaps a more useful approach would be teaching models in a way that emphasizes both the uniqueness and similarities of the various models.

The common factors perspective of therapeutic effectiveness posits that underlying common factors are responsible for the majority of change across all theories of therapy (Lambert 1992; Sprenkle et al. 2009). The common factors perspective offers an additional explanation for conceptualizing therapeutic effectiveness in addition to the perspective that the unique elements of therapeutic models are responsible for therapeutic effectiveness (Sprenkle and Blow 2004a). While the model specific conceptualization of therapeutic effectiveness emphasizes distinctions among models, common factors provide a theoretical framework for attuning to the similarities among models. The common factors perspective provides a way for training programs to continue teaching models while honoring both distinctions and similarities.

It is possible that many programs and professors are currently infusing their courses with information about common factors. Few articles delineate the inclusion of common factors in MFT training (Karam et al. 2015; see also Flaskas 2014; D’Aniello 2015; Fife et al. 2014; Sprenkle et al. 2009). If inclusion of common factors is happening in MFT programs, it is not yet reflected in the literature. Indeed, Nichols (2012) agreed with Sprenkle et al.’s position that common factors are “the overlooked foundation for effective practice” (p. 447). Therefore, we feel it necessary to discuss the rationale for including common factors in MFT training by expanding on Karam et al. (2015) justification.

In this paper, our primary goal is to continue the discussion of why and how to include common factors in MFT training. We offer practical strategies for educators who are interested in including common factors in their current courses. Specifically, we aim to show how common factors instruction can: (a) create a sense of cohesiveness for programs which need to teach breadth of topics that can seem unrelated, (b) help prepare practitioners who are expected to learn many models well but will likely adopt an integrative approach, (c) emphasize basic skills, (d) align with process research, and (e) enhance the richness of individual models. For each of these purposes, we explain the current need and then provide instructions for a classroom activity. We conclude the article with an example of how one student may learn the common factors perspective and weave it into her reflective practices as a student and MFT. Ultimately, our purpose is to support educators as they prepare MFTs for effective practice.

Common Factors in Marriage and Family Therapy

For the past decade, theorists have emphasized the contributions of the common factors perspective to the MFT field (Blow et al. 2007, 2009, 2012; Blow and Sprenkle 2001; Davis and Piercy 2007a, b; Duncan et al. 2009; Sprenkle and Blow 2004a, b; Sprenkle et al. 1999, 2009). Until the common factors perspective, model-specific elements were believed to be responsible for bringing about therapeutic change. The common factors perspective challenged this by proposing that “common factors,” factors common to all models of therapy, may be responsible for the majority of change that happens in MFT (Sprenkle et al. 2009). Common factors began a shift in the field’s understanding of therapeutic effectiveness.

Despite empirical evidence that no one model is superior to others, MFT training has been slow to include common factors in standard training (Sprenkle et al. 2009). The focus of MFT training continues to be organized around teaching models as silos (Karam et al. 2015). Teaching models as silos could stunt the growth of the field because this aspect of the philosophy of MFT education has not followed the trends of research and publications that need to inform training. The lack of integrating the common factors into MFT training may result in undesired outcomes. Meta-analyses by Smith and Glass (1977), (Shadish and Baldwin 2003), Shadish et al. (1995) and Lambert and Ogles (2004) found no difference in effectiveness across treatment models when controlling mediating and moderating factors. This empirical evidence provides strong support for common factors’ contributions to therapeutic change, suggesting that psychotherapy works, not because of the unique contributions of any particular therapeutic model, but because of a set of common factors that cut across all effective therapies (Sprenkle et al. 2009). In other words, the common-factors approach postulates that common factors, or elements of therapy, are the primary contributors to therapeutic change (Sprenkle and Blow 2004a, b). Failure to include common factors in training may result in clinicians whose clinical outcomes are less effective than they could be.

While maximizing positive clinical outcomes is the most important reason for including common factors in MFT training, the lack of inclusion of common factors in training has left many questions unanswerable. When common factors are not consistently included in MFT training programs, researchers cannot examine the impact of the common factors perspective in real-world practice, and cannot examine the possibility of specific skill sets within the common factors (Cornille et al. 2003). An increase in literature focused on integrating common factors in MFT training could support programs that want to include common factors more deliberately. As MFT training includes common factors more consistently, researchers can ask questions relevant to the implementation of the common factors. The result may be an improved way of training new MFTs.

Teaching Common Factors

Common Factors as a Meta-Model

When applying systems theory to the teaching of models, the common-factors perspective becomes a clear meta-perspective that highlights the common factors of change across all models. The systemic theory that serves as the basis of the MFT field emphasizes that each component of a system can best be understood in context of the whole, and in turn, the whole is best understood when each part is examined. When models are considered in context of the profession, shifting from teaching models as separate entities to considering the models in relation to each other is congruent with the systemic approach of MFT. The program can decide whether models or common factors occupy the foreground or background (Flaskas 2014; Simon 2006).

Alignment with Core Competencies and COMAFTE Standards

The concept of common factors as a meta-model fits clearly with the MFT core competencies, which are included as a component of the 2016 COAMFTE standards (Karam et al. 2015). Core competencies in MFT are a collection of basic or minimum skills that each practitioner should possess in order to provide safe and effective care (Nelson et al. 2007). Reviewing the core competencies (Nelson et al. 2007) revealed that though common factors are not identified by name, their influence is present even in places where models are not mentioned. Specifically, “establishing and maintaining therapeutic alliance” (p. 433) is a foundational common factor; “assess clients’ engagement in the change process” (p. 434) emphasizes the common factor of client variables; “reframe problems and recursive interaction patterns” (p. 436) is used for the purpose of disrupting problematic patterns, which was recognized by Sprenkle et al. (2009, p. 37) as a common factor; and “solicit and use client feedback” (p.173) is being addressed in literature as a way for therapists from every theory to improve effectiveness by asking clients for feedback on common factors in treatment (Duncan et al. 2003).

Ways of Incorporating Common Factors with Training in MFT Models

In their article on teaching the common factors, Karam et al. (2015) described the components of the common-factors perspective that they believe should be incorporated into MFT training programs. These include the traditional hallmarks of the common-factors perspective as they have been revised over time: (a) client factors, (b) therapist factors, (c) the therapeutic alliance, (d) hope/expectancy/placebo, (e) interventions common across models, (f) therapist allegiance to the model being used, (g) and feedback (for the original listings of these factors, see Hubble et al. 1999; Lambert 1992; Wampold 2001). Additionally, MFT programs should also teach the MFT common factors which were originally identified by Sprenkle et al. (2009): (a) “conceptualizing difficulties in relational terms,” (p. 35) (b) “disrupting dysfunctional relational patterns,” (p. 37) (c) “expanding the direct treatment system,” (p. 38) and (d) “expanding the therapeutic alliance” (p. 42). We agree that these important components of common factors pose several benefits to MFT trainees. We offer strategies of including common factors in MFT training programs.

Common Factors Meta-Perspective

Common factors can be incorporated into MFT programs in three key ways. First, common factors can be embedded within the overall philosophy of the program. In these programs, the common factors meta-perspective would become a hallmark of the clinical training aspect of the program (see Cornille et al. 2003; Boswell and Castonguay 2007; Castonguay and Beutler 2006). When used as a meta-perspective, common factors guide educators to add to the training of each model by infusing awareness of common factors along with specific models and skills and to present MFT models in a way that recognizes similarities among them. Using common factors as a meta-perspective involves agreement by all faculty members to teach from a common factors lens in most, if not all, areas. This is the most pervasive approach to common factors inclusion that we propose.

A Common Factors Course

Second, common factors can be taught as a separate component of the program, such as when specific courses are dedicated to the common-factors perspective (see Castonguay 2000; Karam et al. 2015). A course in common factors could provide students with a sufficient understanding of common factors, allowing them the flexibility to consider how common factors integrate with the other concepts presented in their training program. This course could be a required course, an elective, or an independent study course for students who are interested in learning about common factors.

Included in an Existing Course

Third, common factors can be included as a component of existing courses such as a theoreties course, basic skills courses, practicum and internship, and supervision. Because common factors are a way to conceptualize therapeutic effectiveness but have not been operationalized in a concrete way and are not a therapy model, the common factors perspective is most useful in therapy practice when implemented in conjunction with an empirically validated therapy model (Karam et al. 2015). Programs that include the common factors perspective within existing courses can demonstrate how to implement common factors with models. Specific aspects of common factors could be emphasized within modules already being taught. For example, the importance of the therapeutic relationship could be included within modules on basic skills in MFT and/or incorporated as a key component of the program (see Angus and Kagan 2007). This way of including common factors differs from common factors as a meta-perspective in that it is less pervasive. Including common factors as a part of one course is not the same as using common factors to guide the clinical training aspect of a program.

Barriers to Teaching Common Factors

MFT’s history as the maverick discipline among helping professions makes it understandable that the commonalities emphasized by the common-factors perspective would not be appealing (Sprenkle et al. 1999). Common factors opponents may feel that emphasizing similarities among models is akin to saying that their particular model has nothing unique or special to offer. Sprenkle and Blow (2004a) explain that models are considered highly important in bringing about therapeutic change; therefore, emphasizing similarities among models may feel dismissive of the importance of models.

Marriage and family therapy program faculty may see their curriculum as too packed to fit in information about the common factors. MFT programs include many essential elements to cover licensure and/or requirements of the Commission on Accreditation for Marriage and Family Therapy Education (COAMFTE) within a limited number of credit hours. Educators can easily feel pressured to teach information quickly and briefly. The idea of adding to classes may seem impractical. These barriers can be overcome by providing educators with a broader range of ideas for how to teach common factors.

Purpose-Driven Common Factors Teaching Strategies

In this section of the paper, we focus strategies for teaching common factors on the desired outcomes, which we refer to as five distinct “purposes.” For each purpose discussed, we present an example of how MFT trainers can integrate each purpose to their existing training programs. Our focus is to present concrete examples for application of common factors principles to training.

Purpose: Create a Sense of Cohesiveness for Breadth of Topics

Providing students with a framework for connecting each topic in the program with the ultimate purpose—becoming an effective MFT—can challenge students to value each class period and assignment. Preparing for practice as MFTs requires students to develop broad knowledge and show competency in several domains. MFT educators must carefully consider which elements to include in their training programs to ensure they align with university accreditation standards, educational requirements for licensure, accreditation standards such as COAMFTE, and core competencies in MFT. Although the importance of each component may be clear to the instructor, students often ask questions like, “why do I need to learn (the topic of the night or even the entire course) if I am going to be working with (the student’s target population)?”

Because students are often most interested in the practical aspects of their training—what actually brings about change for their clients—the common-factors perspective can provide a framework to connect diverse information. When information seems disjointed to students, instructors can refer to the common factors approach and help students see the connection between that information and client outcome. For example, in our experience students often ask why they need to write treatment plans with clients. We refer them to the importance of the therapeutic alliance (a common factor) and highlight research that indicates that working toward clear, common goals is a vital component of the therapeutic alliance. Our students have also asked why it is important to study measurement and statistics. We refer them to the common factor of the hope or expectancy effect and explain that when MFTs understand how to interpret practice research, they can select and adapt evidence-based approaches for working with clients and explain those approaches to clients clearly. We also point out that researchers often make sense of their findings using components of the common factors (e.g., Vaughn 2004).

Example in Action: “Beginning with a Common Factors Framework”

When the professor’s purpose for teaching the common-factors perspective is to create a sense of cohesiveness for program content, introducing it early in the program is most appropriate. This could occur during an orientation to the program, when faculty have an opportunity to reduce student stress by making program expectations clear (Turns et al. 2014), or during an introductory course such as Introduction to MFT. In this situation, the professor could lead students through the steps of a small-scale qualitative research project. The professor could begin by asking for two or three volunteers to write on the chalkboard or whiteboard. When volunteers are prepared to write, the professor introduces the exercise by saying something like, “You decided to embark on an intense journey when you committed to this program. You’re planning to make many personal and relational sacrifices, and you’re paying a lot of money to do this. What is your ultimate goal in beginning this program?” Students will likely respond with, “to be a therapist,” “to help people,” and “to graduate and make money!” The professor can accept those responses while prompting for more by asking, “What do you hope will happen when you are working in your future jobs?” Responses will turn to doing the most effective work possible and helping clients make the changes they desire.

The professor can then pose the question, “Brainstorm with me for a few minutes—what do you think creates change in MFT? What are hallmarks of effective MFT?” The volunteers write each comment on the board. If students have a difficult time coming up with more than a few ideas, the professor can prompt with questions like, “What are some characteristics of effective MFTs? As wonderful as we all are, we don’t get all the credit; what happens to support client change that is out of our hands or that we can only influence?” Once students have provided a range of responses, the professor directs them to look for themes. When the group decides on one theme, a volunteer can write that theme and then visually indicate which comments fit into that theme by using a particular color of chalk or marker to circle every comment in that theme or, if multiple colors are not available, themes can be noted by using designs such as circling words, drawing a square around words, putting a star by words, or various styles of underlines. The themes will likely be somewhat similar to the common factors. At that point, the professor can provide a very brief overview of common factors, highlighting that this perspective provides a meta-perspective for conceptualizing change in MFT. The importance of learning specific models should be emphasized also, so students do not erroneously belittle the importance of thoroughly learning models.

The professor can then transition with, “We pack these next few years extremely full of information, assignments, practice exercises, opportunities for reflection, and challenges to grow. It can be overwhelming at times, and in the hectic nature of juggling life, clients, and classes, it can feel like some aspects of the program don’t matter much. When you feel impatient, I would encourage you to remember these common factors. This can help you make sense of a tremendous amount of information by organizing it into this simple meta-framework. It can also connect what you are learning each day to how you will use it in your future work with clients.” The professor can then use examples of how specific courses and program requirements fit into the common factors. For example, basic skills courses teach principles of the therapeutic relationship; theories courses teach models; learning about psychopathology, diagnosis and issues such as domestic violence, substance abuse, and multicultural sensitivity honors client variables. To help students refer to this foundation throughout the program, a handout with the common factors in MFT (perhaps based on Sprenkle et al. 2009) could be provided.

Purpose: Learning Many Models While Preparing for Integration

MFT training programs have largely moved past clinical training that focuses on teaching a singular approach to treatment (Karam et al. 2015). Many training programs require students to demonstrate knowledge of several theories and encourage each student to choose a primary model that he or she will use when treating his or her clients. Programs support students as they struggle to implement the chosen model and allow students to change models thoughtfully. Therefore, trainees are faced with the opportunity and challenge of learning multiple treatment models. Organizing MFT training around teaching models as separate entities creates challenges for students. First, this method not only overlooks meta-analytic research that finds no one model superior to others (e.g., Shadish and Baldwin 2003; Wampold 2001; Wampold et al. 1997), but also risks giving students the erroneous message that models are primarily responsible for the change that occurs in therapy. Third, the focus on models may seem to diminish the influence of the client, while studies examining contributing factors of change consistently prioritize the client’s contribution (Thomas 2006; see also Bohart 2000). Finally, the number of distinct models can be overwhelming to students.

Ironically, as the number of models is increasing, the number of practitioners who adhere to one specific model is decreasing. At this point, the majority of MFT clinicians report practicing models in an integrative fashion (D’Aniello 2015; Barth 2014; Davis et al. 2011; Norcross 2005; Thomas 2006; Woolfe and Palmer 2000; see also Nichols 2012). In her study of clinicians who work with couples and families, Perkins (2010) 398 participants reported using an average of 4.25 theories (SD = 2.52). Additionally, Bradley et al. (2010) surveyed MFTs and asked them to rank order the five theories that most influenced their work. Note that the authors expected participants’ work to be influenced by at least five theories, and they reported that the theories chosen varied greatly. Therefore, it is realistic to assume that many trainees of today will become integrative therapists of tomorrow. We believe that training in the field should recognize, prepare, and plan for this. There is concern that therapists may approach integration haphazardly, and multiple articles recommend a systematic, deliberate approach to model integration (Piercy and Sprenkle 1988). The common factors can be used as a basis for integrative approaches (Lebow 2008; Sprenkle et al. 2009). If common factors are awarded a more prominent role in training, trainees may develop a more sophisticated understanding of model integration earlier in their careers because the common factors can guide MFTs to examine the underlying principles and assumptions of models, which leads to more purposeful synthesis of the components of models that the MFT sees working together. Fortunately, professors who want to incorporate the common factors and/or teach integrative approaches can use resources such as Lebow (2013), which includes chapters and exercises on common factors and integration of theories. Articles focusing on underlying principles of MFT models may also be helpful (see D’Aniello 2013 for an example). Ultimately, the purpose of MFT education is to prepare effective practitioners and trainees who integrate models thoughtfully and intentionally, in other words, those who know what they do and why they do it tend to enjoy better treatment outcomes (Nelson and Prior 2003; Taibbi 1996).

To address these challenges, the common-factors perspective can be presented as a meta-approach to understanding therapeutic effectiveness. Specifically, common factors highlight how all MFT models produce similar client outcomes. Sprenkle and Blow (2004a) explained that a common-factors perspective simply shifts the assumption of why models work, which is that many MFT models are predicated on a more finite set of mechanisms for change.

When introducing common factors to master’s students, it must be situated in relationship to students’ existing understanding of models and change. Common factors can be presented as another way to understand how change occurs in therapy and what therapists do in order to facilitate that change. Common factors lens must be applied ‘on top of’ a theoretical model (Davis and Piercy 2007a, b). Following a basic explanation of what common factors are and how they can be useful, it is important that students understand a brief history of common factors in psychotherapy and MFT.

Example in Action: “Common Factors Meta-Perspective”

Beyond reading and classroom instruction about common factors, students need to experience and integrate common factors into their thinking and practice. It is important for common factors to ‘come alive’ for students, rather than remaining nebulous ideas written about by academics in journal pages. To provide students with an experience of common factors, the professor could engage the class in an activity. He or she could cover the walls of the classroom with large poster paper; students would be asked to go around the room and write their favorite model at the top of one of the papers. Once students have done this, the professor could direct students to list the core assumptions, tenants, and techniques of each model. Once students generated comprehensive lists, the professor could instruct students to draw linkages among foundationally similar concepts. For example, under narrative therapy, students would likely write “developing an alternative story;” and under solution-focused therapy, “seeking exceptions to the problem” would be listed. Students would be able to identify common links between these concepts in that they rely on client insight and ask the client to turn his or her attention or focus to problem alternatives. Reviewing MFT models with the focus on their underlying characteristics and finding commonalities among them helps students begin to orient their thinking toward common mechanisms of change rather than model specific language.

Purpose: Basic Skills as a Method for Establishing and Maintaining the Therapeutic Alliance

As a result of model-driven training, basic therapy skills may take a back seat to learning the hallmark techniques of models, and important skills such as reflective listening, reframing, and engendering hope are rarely formally taught independently from models (Blow and Sprenkle 2001; Sprenkle and Blow 2004a). We believe that a solid foundation in basic skills training aligns well with common factors, as therapists who possess strong basic therapy skills are best equipped to activate common factors in their therapy sessions. Additionally, we caution that basic skills are not a direct operationalization of common factors and are not a sufficient therapy model. Rather, the basic skills are tools therapists use to develop and maintain a positive working relationship with clients, which is one of the main components of the common factors. Additionally, common factors remind students that there is more to therapy than the application of the model. Training in common factors refocuses attention to the therapeutic relationship, which includes learning and practicing general therapy skills such as active listening, tracking, question formulation, and goal setting.

Example in Action: “Common Factors Skills Lab”

Creating a common factors-based ‘skills lab’ in the classroom can be a method for ensuring that training therapists learn and practice implementing essential skills. To provide an opportunity for students to apply basic skills in situations they are likely to face with clients, the professor could organize a ‘skills lab’ around each of the common factors and MFT common factors. The professor could create flash cards with scenarios lending themselves to each common factor. Students would blindly select a card and then role-play the scenario with simulated clients (classmates). Classmates would then be asked to provide constructive feedback to each therapist. For example, a card may read: “You are seeing a new couple and each time the male partner begins to speak, the female partner interrupts him and begins to verbally berate him. Though you recognize that this pattern is dysfunctional to treatment, you have trouble interrupting it.” Students would be assigned the roles of clients, therapist, and observer(s). The therapist can use his or her preferred model combined with a common factors lens to practice interrupting dysfunctional patterns and intervening when clients are yelling and tensions run high, a scenario which is difficult for most beginning therapists. In this example, classmates might recommend using nonverbal cues and the student could practice shifting his or her body position to be more open to the male partner and turned away from the female partner when she interrupts. Another classmate might recommend using immediacy and tracking to discuss this with both partners. The student in the role of therapist could try each suggestion and debrief with the team. Classmates can then discuss feedback, which may include the therapist’s preferences, the role-play client experiences, and the observer’s notes. Providing the forum for trainees to practice skills in the safety and support of the classroom serves to enhance their confidence when they utilize these skills in practice.

Additionally, basic skills related to common factors can be incorporated into supervision, in which beginning therapists can be asked to consider the underlying mechanism of change in the model they are using, why they are using that model, how to gauge the client’s response, and how to shift gears if it is not working. Students can also find evidence of common factors at work in training videotapes. For example, the therapist often enhances hope and expectancy variables in the treatment.

Purpose: Align with and Support Process Research

In addition to including common factors in clinical aspects of MFT training, common factors can be integrated into research in MFT programs. This example is intended to illustrate how common factors align with and support process research. Process research and common factors have both been identified as potential ways to narrow the researcher-practitioner gap (Sprenkle and Blow 2004a, b; Oka and Whiting 2013). Process research is a term that refers to research that examines what goes on within therapy, or examines the behaviors and patterns inherent in the therapy process (Oka and Whiting 2013; Pinsof and Wynne 2000). Process research aligns with common factors, as common factors are therapy process elements. For example, Lambert (1992) identified therapeutic alliance, client factors, therapist factors and expectancy variables as common factors or process factors that influence the outcome of therapy. Currently, process researchers are beginning to cite common factors research as theoretical support for their research. Kneer et al. (2011) cite common factors, and Wampold (2001) suggested that extra therapeutic factors influence change in psychotherapy and further discussed ways their work “…extends common factors research” (p. 183). Because of the acknowledgement of a gap between research and practice in the MFT field and the detrimental impact of this gap, it is critically important to teach the next generation of MFTs to conduct and consume research that informs practice.

One approach to teaching MFTs to be informed by research is to introduce them to client feedback methods. Client feedback can provide insight into what is and is not working for the client and can allow MFTs in training to quickly learn what clients perceive as their strengths and growth areas in session. The discussions between client and MFT prompted by client feedback can focus on therapeutic processes and ask specifically about the common factors.

Example in Action: “Creating a Culture of Collecting Client Feedback”

Therapists who receive honest feedback about their work achieve better outcomes (Harmon et al. 2005; Lambert 2005; Lambert et al. 2005; Sprenkle et al. 2009). Creating a culture of soliciting client feedback in university training clinics is an ideal way to support process research. Developing the habit of collecting and incorporating feedback is best begun early in one’s career, before words like ‘feedback’ and ‘evaluation’ become scary. Whereas the previous examples in action have been classroom activities, the present example is intended for use in clinical practice and supervision.

Supervisors and educators can implement a feedback collection system in their university training clinic. Several client feedback scales have been developed (Pinsof and Lebow 2005; Pinsof and Wynne 2000); perhaps the best known and most widely used are the Session Rating Scale (SRS) (Johnson, Miller and Duncan 2000; see Duncan et al. 2009) and the Outcome Rating Scale (ORS) (Miller and Duncan 2000; see Miller et al. 2003). These scales provide a forum for clients to provide feedback on their progress (ORS) and each session (SRS). These scales address common factors such as the therapeutic relationship, client factors, and sense of hope or expectancy in therapy (Johnson et al. 2000).

Educators and supervisors should encourage students to use the results of feedback scales both immediately and longitudinally. For example, therapists can review a client’s feedback scores prior to session and inquire about a particularly low rating; also, therapists can review a client’s feedback scores and immediately address feedback indicating the client felt a session did not go well. During weekly supervision, therapist and supervisor can review and discuss client feedback as they analyze individual client progress. This use of client feedback in supervision demonstrates to students that feedback is useful and informative for tailoring sessions to clients’ specific needs. In addition to use in weekly supervision, client feedback can be collected, tracked, and analyzed longitudinally. At the end of each semester, supervisors and educators can review the feedback and outcomes of each therapist’s clients. Using client feedback in this way allows therapists to be reflective of their own practice and outcomes.

Purpose: Emphasize the Importance of Client Factors

Thomas (2006) asked clients and clinicians what they thought contributed to the outcome of therapy and reported that they agree: the client contributes the most to change in a therapeutic process. Tallman and Bohart (1999) noted, “nearly all approaches [to therapy] recognize the importance of client collaboration to make therapy work” (p. 94). Although research often focuses on experiences of specific demographic groups of clients (e.g., Bischoff et al. 2014; Clark and Kimberly 2014; Epstein et al. 2014; Guregard and Seikkula 2014; Mirecki and Chou 2013; Murray 2014), reviews of MFT curriculum suggest that when client factors are included in MFT training programs, they are addressed as grouped demographics in courses that teach developmental stages, individual psychopathology, sexuality, and information about ethnic minorities, or as specific problems clients deal with such as history of abuse, grief, crisis and trauma, domestic violence, or substance abuse issues. Two problems may arise with this approach to teaching client factors. First, this information is typically separated from theory and application in MFT, leaving students to guess how to adapt their approach to clients. Second, teaching client factors in groupings neglects the individual characteristics, strengths, and idiosyncrasies of each client. The common factors perspective posits that client factors are perhaps the largest contributor to change in therapy but does not explain how MFTs can engage clients to maximize the change potential of client factors. Because each client is unique, perhaps the best way to teach client factors is to focus on basic skills and obtain feedback from clients (Gordon 2012).

Example in Action: “One Family, Diverse Experiences”

The following activity is an example of a classroom activity that can be conducted in order to highlight the importance of adapting therapy to each unique client system. The professor could show a video clip of a family with unhealthy dynamics. The professor would ask students in the class to organize into groups so that each group had the same number of students as the family members in the video clip. Once the students were in groups, the professor would ask each student to plan to take on the role of one of the family members. In this way, the class represents multiple groupings of the same family. The groups would then role-play the family dynamics while discussing a topic relevant to the video clip. Once the students appeared to be thinking like the family members, the professor could ask one group to volunteer for a role-play for the larger class. The professor would act as the therapist and demonstrate a therapy technique. For this activity, any technique would work, but one which elicits strong emotions would likely work best. The volunteers would then return to their “family” groups. The professor would ask students to stay in character and think about what their experience with the session would have been. At this point, the professor would give “family members” a feedback form for the session [e.g., Session Rating Scale (SRS)] and ask them to provide feedback on the session as the family member. The professor would collect these forms, keeping the forms in family groups. The class could take a break while the professor reviewed feedback from each family.

Next, the students would shift and think from the therapists’ perspective. Just based on the therapists’ experience in the role-play, what would the therapist likely perceive the family’s experience would have been? Students could discuss this briefly, with likely responses including, “some tough moments, but overall fairly good.” Then the professor would invite “families” to share what they think their experiences would have been with the class. It is likely that some “families” would have valued and appreciated the session while others would have hated components of the session; it is also likely that the “families’” perceptions are in stark contrast to the therapist’s perceptions. The feedback forms could be reviewed to emphasize differences in perception. The more students’ responses vary, the more clearly the points are illustrated. If desired, the professor could resume the role-play with the “family” and discuss feedback from the “clients.”

The professor could then point out and ask, “Therapists can only see through their own eyes. How can we possibly know when clients experience sessions so differently than we think they did?” Students will likely point to nonverbal responses and body language, which can be included in the importance of obtaining clear client feedback. The professor can then emphasize, “Even though each ‘family’ today saw the same video and the same session, each ‘family’ had a slightly different response to the session. The same happens with clients—each client is unique and will respond to you and to interventions differently.” The professor can explain that obtaining client feedback helps therapists honor the uniqueness of each client and individualize treatment in a way that works for that particular person.

A Unifying Example

We present this final example from a students’ perspective. We see this type of student thought process happening as a result of purposefully integrating common factors into a MFT training program. Notice that this example incorporates the goals of this paper.

A therapist is interested in conducting some process-oriented research to better understand how her application of her preferred model, narrative therapy, brings about change in her clients. The therapist decides that the best way to answer this question is to observe and analyze her recorded session videotapes. When reviewing her tapes, the therapist notices commonalities among her sessions. The therapist observes her own attempts to form strong therapeutic relationships with her clients through listening to the problem-saturated story and expressing empathy (White and Epston 1990). The therapist notices that clients are willing to become vulnerable in session when she has established strong therapeutic relationships. Further, clients who demonstrate vulnerability readily follow her lead toward change, placing their trust in her process. The therapist notices that when she senses she has gained her clients’ trust, she intervenes by helping clients externalize the problem. The therapist notices this unique common factor in her process of forming an alliance with her clients, engendering hope, and gaining clients’ trust in her application of narrative therapy.

The therapist notices that clients who enter therapy with an orientation to insight into their problem often change more quickly than those who do not demonstrate insight. The therapist notices that clients who internalize the alternative story, are willing to consider unique outcomes, and engage in letter writing are clients who change their behavior after acquiring new insight. The therapist identifies insight as a primary mechanism of change in narrative therapy. Insight as the mechanism for change becomes clearer to the therapist when she observes tapes of clients who did not continue treatment or did not make change. The therapist notices that these clients were not able to change their behavior as a result of insight; therefore, narrative therapy was not successful with these clients. The therapist decides that next, she will examine the process by which clients develop insight, her role as the therapist in facilitating the development of insight, and how to recognize when this is not working for a client. In this above example, the therapist learned a great deal about her practice style by simply observing her tapes and doing some informal coding. Blending common factors understanding with narrative therapy enhances the richness of the model. The common factors elements encourage the therapist to consider aspects of the application of the model, client, therapeutic relationship, and the context in which the model is applied.

Future Directions for Integrating the Common Factors Perspective in MFT

As the common-factors perspective becomes further integrated in MFT training, it will impact various aspects of the field. Looking ahead, including the common-factors perspective in MFT programs is likely to prompt varied and in-depth research on the implementation of the common-factors perspective. This research can blend with process research to better explain what is actually being done in sessions that impacts client change.

Incorporating common factors in MFT training carries important implications for clinical practice, training, and research. We have detailed how the common-factors perspective can be used to inform intentional model integration by focusing on underlying principles, emphasizing therapy skills, supporting process research, and emphasizing client factors. Each of these concerns has been identified as important in other research, though practical suggestions for implementation had not been addressed. The present paper offers a starting point for educators to begin incorporating common factors into their courses. At the core of the present paper is an effort to improve MFT training, which, in turn, improves the quality of MFT services clients receive. Further, we agree with Karam et al. (2015) that it is important to continue the conversation about the role of common factors in the MFT field. We believe that the MFT field has much more to gain by emphasizing the common factors in training new professionals and examining the outcome of this training.