Introduction

No two therapists treat a case exactly the same way (Sprenkle et al. 2009). Further, therapists of the same theoretical orientation achieve different clinical results (Sprenkle et al. 2009). Variation in treatment process and outcome speak to the unique, human elements inherent in the therapeutic process, which set the practice apart from physical healthcare treatment. Many theorists argue that therapy is more complex than the application of a model to a presenting problem. The majority of therapists report using an integrative or eclectic approach (Norcross and Newman 1992; Davis et al. 2011; Norcross and Goldfried 2005; Barth 2014; Woolfe and Palmer 2000). Integrative approaches draw from a broad theoretical basis, and are flexible enough to account for a wide range of human behavior (Lebow 1987). Despite the widespread use of integrative practice styles, training in MFT remains predominantly driven by the teaching, practice and supervision of models (Sprenkle et al. 2009). The process of how change occurs, therapy techniques and interventions and problem conceptualization are taught primarily through the lens of models. The disconnect between how MFT’s are trained and how they practice may present new graduates with difficulty as they acclimate to their post-master’s careers. Perhaps evidence of the pervasive and widely acknowledged integrative movement is becoming apparent, as some MFT master’s programs are beginning to train and encourage thoughtful model integration. One way for students to conceptualize and refine their way of integrating models is through a theory of change project (Nelson and Prior 2003). Trainees may struggle with such a project, as it requires a high degree of conceptual skill and theoretical mastery.

Training therapists would benefit from a simple, yet clear and explicit road map to guide them through model integration. The common factors approach is one possible road map. The present conceptual paper presents a rationale for the usefulness of the common factors approach as an integrative construct (Weeks and Chad 2004) for integrating MFT models. I will present three key ways that common factors inform integrative theorizing by serving as a useful meta-model to guide trainees in integrating models. The common factors approach (1) reminds us that models are more alike than different (2) directs attention to common mechanisms of change and (3) focuses attention on process variables.

Though there have been other works (e.g. Karam et al. 2014), addressing the role of common factors in training and model integration, the present paper is unique in several key ways. First, the present paper highlights areas of contention between MFT training and the reality of real-world therapy practice. Second, this paper focuses on the specific needs and challenges of trainees and novice therapists, as it is intended to be useful to those who train and supervise MFT students. Third, the present paper demonstrates the usefulness of the present form of common factors as an integrational construct, without developing an additional integrative model (such as Breunlin et al. 2011; Pinsof et al. 2011). The present paper is intended to help novice therapists begin to understand model integration; and therefore focuses on simple, pragmatic ways to apply the common factors approach. Finally, this present paper stresses the importance of intentional therapy practice, knowing what you do and why you do it (Nelson and Prior 2003; Taibbi 1996).

Literature Review

Moderated Common Factors Approach

The common factors approach came about when research failed to find significant differences in treatment outcome for different therapy models (Ahn and Wampold 2001; Shadish and Baldwin 2003; Wampold 2001). Based on these meta-analytic results, researchers and theorists considered the possibility that factors, common to most therapy models, were the primary contributors to change in therapy (Lambert 1992). According to the common factors approach, common elements embedded in many therapeutic models, are curative, though they are not the hallmark of any one model (Sprenkle and Blow 2004; Sprenkle et al. 2009). Lambert (1992) hypothesizes that only 15 % of variance in treatment outcome is due to the therapy model and specific techniques, a surprisingly minimal amount.

Historically, MFT model developers and theorists believed that models were responsible for producing change, while common factors proponents disparaged teaching models, in favor of teaching broad therapy skills, or common factors, including therapeutic alliance building, active listening and instilling hope (Hubble et al. 1999; Sprenkle et al. 2009). These opposite perspectives have contributed to polarizing thinking and a conceptual divide between models and common factors (Sprenkle et al. 2009). Sprenkle and Blow (2004) narrowed the gap between these opposing perspectives by advocating for a moderated common factors approach, and being overt about the important and prominent role of models. The moderate approach to common factors asserts the position that there are relatively small overall differences in treatments among effective therapies (Sprenkle and Blow 2004). According to the moderated common factors approach, models work because they are vehicles through which common factors operate (Sprenkle and Blow 2004). In other words, models activate and potentiate the underlying mechanisms for change (Sprenkle and Blow 2004). Both common factors and therapy models are regarded as important components of effective therapy (Sprenkle and Blow 2004).

Integrative Movement in MFT

Historically, marriage and family therapy (MFT) training and practice involved learning and practicing a single therapeutic model, though a trend toward integrative clinical practice in marriage and family therapy has been well documented for quite some time (Lebow 1987, 1997; Breunlin et al. 2011; Pinsof et al. 2011). Integrative practice is common and widely accepted in the field, and has sparked a paradigmatic shift away from definitive schools of thought or models, toward integrative practice (Lebow 1997). Survey studies of MFTs preferred practice model find that the majority of MFTs identify themselves as integrative practitioners (Norcross and Newman 1992; Smith and Southern 2005). By definition, theoretical integration involves the process of connecting concepts and interventions from several therapy models (Lebow 1997; Norcross and Goldfried 2005). Most experienced therapists do not use only one or two approaches in their work (Northey 2002; Orlinsky and Rønnestad 2005). Model integration implies blending models at the theoretical and practice level, and also involves creating a new, integrative theory that moves beyond the two original approaches being integrated.

Lebow (1997) outlines nine primary factors that have given way to the widespread acceptance and practice of integrative therapy models. A philosophical underpinning of integrative perspective is a broad view of the change process (Lebow 1984). Integrative therapy approaches offer a range of choices and enhanced flexibility, thereby increasing the likelihood of therapeutic efficacy (Lebow 1997). The integrative trend is consistent away from the modernist belief that a single model could save the world. Rather, integrative approaches support a postmodern understanding of the limits of any model (Lebow 1997). The acceptance of family therapy as an important mental health discipline has reduced the propensity to highlight distinctiveness between MFT and other approaches, but rather, promotes examination of commonalities among MFT and other disciplines (Lebow 1997). Adherence to a systemic perspective invites examination of factors that lie within and outside of the system (Lebow 1997). Fifth, MFTs commitment to diversity “…promotes discourse that transcends scholastic boundaries” (Lebow 1997, p. 2). Clinical practice is highly pragmatic, in that practitioners tend to gravitate toward interventions that facilitate effective therapy, no matter their theoretical origin. Research on the practice of MFT has failed to demonstrate the superiority of one model over others (Lebow and Gurman 1995; Lebow 1997). Finally, MFT therapists have a historical association with the treatment of difficult clinical disorders including eating disorders, substance abuse and schizophrenia (Lebow 1997). Given the complex and often inter-disciplinary nature of these disorders, integrating family therapy and individual therapy became recognized as an efficacious treatment method (Lebow 1997). The synergies among these nine factors have contributed to the roots of the movement toward theoretical integration in the MFT field (Lebow 1997). Despite the widely acknowledged integrative movement in MFT practice, MFT training has not followed this trend.

MFT Training

Unique Needs of Novice Therapists

It is well noted in the literature that couples and families present therapists with unique challenges (Glebova et al. 2011; Symonds and Horvath 2004). Therapists have unique needs based on their developmental stage (Andrews et al. 1992; Loganbill et al. 1982). Therapists may experience increased difficulty treating relational clients due to the complexity of simultaneously balancing many client variables (Glebova et al. 2011). A study by Stolk and Perlesz (1990) found that client satisfaction was lower when their therapist possessed two or fewer years of training experience (Laszloffy 2000). Beginning therapists often underestimate family treatment case complexity, applying a reductionist lens to family processes (Andolfi et al. 1993). Family therapy practice is often pragmatic, a stance which aligns well with an integrative approach (Lebow 1997). Particularly novice therapists, strive to enhance the efficacy of their practice.

Teaching Models

Training in MFT has not followed the practice trend toward integration and continues to be organized around teaching models (Karam et al. 2014; Sprenkle et al. 1999, 2009). Primarily, MFT training programs teach models as separate entities, and typically, in isolation from one another (Andrews et al. 1992). Sprenkle and colleagues believe that the over-focus on models has held our field back from acquiring a deeper understanding of why change occurs through the therapy process (Sprenkle and Blow 2004). Karam et al. (2014) believe that encouraging trainees to select and focus their practice on a single model does not reflect the reality of real world MFT practice.

Theoretical Integration Assignments

Many master’s level training programs require a theoretical integration assignment, or a paper describing their personal way of integrating MFT models (Nelson and Prior 2003). Theoretical integration papers pose several benefits. Theoretical integration papers, or personal model papers require trainees to describe their way of integrating MFT models (Taibbi 1996; Nelson and Prior 2003). Theoretical integration assignments draw awareness and intentionality to the therapeutic process; they also serve as a road map for the therapy process. Therapists who demonstrate an understanding of what they do in therapy, how they make decisions and how they determine interventions used, tend to be better therapists (Taibbi 1996; Nelson and Prior 2003).

The phenomenon of theoretical integration assignments at the training level is relatively new and unexplored. Lebow (1997) states “many family therapists are at the mid-life, a point where clinicians have the experience and skills to integration…” (p. 2). Similarly, Karam et al. (2014, p. 13) believe that competent model integration is accomplished after years of clinical practice of multiple theories, various clients, supervision and self-of-the therapist work. However, more and more commonly, trainees are encouraged to practice integration at the beginning of their careers, typically while they are still in training. The implications of integration early in one’s career are relatively unexplored. Though integrative practice has become a common phenomenon, (Lebow 1997) students and novice therapists and trainees may experience difficulty integrating models at the level of theorizing. Despite learning several models, often, trainees have not had specific training in how to integrate models (Lebow 1987). The common factors approach is a particularly useful theoretical lens for guiding integrative theorizing in three key ways: (1) reminds us that models are more alike than different (2) directs attention to common mechanisms of change and (3) focuses attention on process variables.

Common Factors as an Integration Guide for Novice Therapists

Common factors training can provide a conceptual basis for thoughtful model integration (Cooper and Mcleod 2007). Integration marks higher-order theorizing through blending of models into a meta-level theory (Lebow 1997). Karam et al. (2014, p. 1) “…believe learning about common factors is an excellent way to bring about a theoretical as well as empirical integration, not otherwise possible when the focus is on competing models”. An overarching common factors theoretical lens encourages therapists to be thoughtful and about the elements of models they integrate, and for what purpose. Using the common factors approach as an overarching guiding theory serve as a roadmap to intentional model integration.

Models: More Alike Than Different

Smith and Southern (2005) discuss how the common factors approach to integration can inform technically eclectic practice by identifying effective therapeutic process elements.

Rather than focusing on uniqueness of models, common factors reminds therapists that there are common elements of therapy that they must attend to no matter what model they use. For example, therapeutic process elements, also called broad common factors including therapeutic alliance, expectancy variables, and engendering hope are all principles that are universally applicable to the therapy process regardless of the model chosen.

The common factors perspective focuses on similarities rather than differences among models. However, in training, models are typically presented from a perspective that emphasizes differences (Karam et al. 2014). Considering areas of agreement among models marks a shift in thinking. Trainees must examine models’ commonalities and areas of agreement, such that they can be integrated. The common factors perspective reminds us that models are more alike than different. The common factors approach assures novice clinicians that choosing one model does not mean giving up the benefits of others (Sprenkle and Blow 2004). Rather, since models contain many of the same elements, choosing one model is likely to incorporate several benefits of other models. For example, narrative therapists often ask exception questions, about what happens when the problem is not happening (White 2007), which is consistent with solution focused therapists who emphasize client strengths (De Jong and Berg 2008). Though expressed using different language, these two models accomplish a similar goal.

This idea of similar elements in many models is consistent with the narrow conceptualization of common factors. In this narrow sense, the term ‘common factors’ refers to the therapeutic intervention techniques that are embedded in all effective therapy models (Blow et al. 2007). Change mechanisms in the various MFT models are overlapping (Henggeler and Sheidow 2002; McFarlane et al. 2002). Rather than focusing on the unique techniques of a branded model (Lebow 2013) a focus on common factors draws trainees’ attention to the underlying mechanism for change (Norcross and Newman 2003).

Attention to Mechanisms of Change

Where most models advertise and promote branded techniques, the common factors approach draws attention to the underlying mechanism for change embedded in many models. Mechanisms for change are processes that lead to or bring about therapeutic change (Kazdin and Nock 2008). For example, cognitive behavioral therapists believe that change occurs through altering cognitions and thought patterns, while psychoanalytic therapists believe that change occurs by making the unconscious conscious, while family therapists believe change occurs through the process of changing interactional dynamics (Wampold 2001). Change mechanisms in various models are overlapping, and many models rely on the same change mechanisms (Henggeler and Sheidow 2002; McFarlane et al. 2002; Sprenkle and Blow 2004). A common factors approach to model integration reminds trainees to consider the change mechanism that each model utilizes. Incorporating mechanisms for change into training and supervision can be accomplished through considering how does the client change, and considering what interventions work best with each client.

Attention to underlying mechanisms for change inherent in MFT models is consistent with the narrow conceptualization of common factors. The narrow view of common factors describes nonspecific aspects of MFT models that are found in many models, though labeled with or using different names (Lambert 1992; Sprenkle and Blow 2004). For example, many models describe the intervention of helping clients alter meaning around the problem. Some models call this process reframing, while others call it externalizing the problem (White 2007). Despite the different names, the mechanism for change in both models involves helping the client acquire new insight, or meaning about the problem. The narrow conceptualization of common factors shifts our attention from branded techniques, to the underlying mechanism of change.

Focus on Process Variables

In addition to the narrow conceptualization, common factors have also been broadly conceptualized (Lambert 1992; Sprenkle and Blow 2004). Broadly conceptualized, common factors include process variables that are inherent in the treatment setting, including therapist factors (Wampold 2001), therapeutic alliance (Bordin 1979) and expectancy variables (Hubble et al. 1999; Karam et al. 2014; Sprenkle and Blow 2004). Each of the above mentioned areas have been found to impact therapy treatment outcomes.

Teaching trainees about process variables through the common factors approach provides a theoretical basis for the importance of these factors. Trainees’ ability to conceptualize the impact of process variables is an important area of skill development and is applicable regardless of the model(s) being used. Encouraging MFT trainees to continually hone basic therapeutic skills such as joining, reframing, active listening, tracking, and question formulation is important regardless of the model used. At times, it is easy to overlook the most basic tenets of effective therapy. Trainees and novice therapists may easily become entangled in model integration at the theoretical level, and overlook the importance of continuing to hone basic therapeutic skills. Broadly conceptualized common factors remind students of the importance of process variables and basic therapeutic skills.

Discussion

The majority of MFT therapists report practicing integrative therapy, (Davis et al. 2011; Norcross and Goldfried 2005; Woolfe and Palmer 2000) which presents realistic and timely concerns for training. It is a particularly realistic concern that trainees and novice therapists may approach integration haphazardly, though research recommends a systematic, deliberate approach to model integration (Piercy and Sprenkle 1988).

The common factors approach reminds trainees that models are more alike than different. A central disconnect occurs between how MFT models are often presented and taught and how they are used in real-world practice (Karam et al. 2014). When models are initially taught, areas of distinction and difference are highlighted. This way of teaching models may leave students believing that models are distinctly different from one another. The belief that models are inherently different becomes problematic when students attempt to integrate models. Integrating models at the levels of theory, strategy and intervention (Lebow 1997) involves examining common tenets upon which this integration can occur. Incorporating the common factors approach into training of models serves to provide students with a perspective that is balanced between model similarities and distinctions.

Sprenkle and Blow (2004) explain that the common factors perspective shifts the assumption of why models work. The assumption that models work because of branded techniques shifts to the assumption that models work because they enact a finite set of mechanisms for change. For example, psychodynamic therapy, cognitive-behavioral therapy, and narrative therapy rely on insight (think something different) as the primary mechanism for change, while structural and strategic therapies rely on behavior change (do something different) as the mechanism for change. This paradigm shift may provide a valuable foundation for students’ understanding of theory and how theory applies to practice.

MFT training does particularly well in making sure that students understand the important contribution of MFT models, where training sometimes lacks, is ensuring that students understand the importance of process variables. Sprenkle and Blow’s (2004) moderated common factors approach argues that “models work because they are the vehicle through which common factors operate” (p. 115). Therefore, when training students from a moderated approach to common factors, models and common factors work together and potentiate one another.

Implications

Using the common factors approach as scaffolding to guide thoughtful model integration carries important implications for training, therapy practice and research in the MFT field. Given the widespread popularity of integrative practice, it is practical and timely to teach MFT trainees how to thoughtfully and intentionally integrate models. The ability of the common factors approach to guide thoughtful model integration is an important reason to award the common factors approach a more prominent role in MFT training. Including common factors in MFT training, with specific emphasis on the ability of the common factors approach in guiding integration would mean that the next generation of MFTs are much more prepared and equipped to practice thoughtful and purposeful model integration. The next generation of MFTs would be better equipped to practice intentional model integration as opposed to atheoretical eclecticism, or haphazard selection of techniques and interventions (Karam et al. 2014; Sprenkle et al. 2009). If awarded a more prominent role in MFT training, the common factors approach could be instrumental in helping trainees develop a sophisticated understanding of model integration early in their careers. The overarching purpose of MFT training is to prepare effective practitioners, and trainees who integrate models thoughtfully and intentionally, and those who know what they do and for what purpose, have better treatment outcomes than those who do not (Taibbi 1996; Nelson and Prior 2003).