Making Common Factors Common in EBP Practice

This podcast is produced by the Center for Deployment Psychology at the Uniform Services University of the Health Sciences. The views expressed are those of the speakers and do not necessarily reflect the opinions of the Uniform Services University, the Department of Defense or the U.S. government. In addition, references to any specific companies, products, processes, or services does not necessarily constitute or imply endorsement by the Uniform Services University, the Department of Defense or the U.S. government. Welcome to CDP's podcast, practical for your practice. CDP's podcast about evidence-based psychotherapies. I'm Dr. Kevin Holloway. I'm here as usual with Jenna Irmall and Andy Santanello. Here's what I'm going to say. Hi. Hi. Hello. And joining us today is a good friend of mine for many years, Dr. Michael Jones. And actually, he was with CDP's, and he's a great writer and he's a great writer. And actually, he was with CDP not so long ago, but he's moved on to other interesting things. Michael, tell us about yourself. What you're doing. Hey, everyone. Yes. So if you were a big fan of CDP and spend all of your time following them, you may have seen me and I do make a few appearances and a few sleep videos as well. That's right. I'm the guy with the butch in and the receding hairline. So, so many of my Jones, I'm a psychologist. I work, I currently work as a contractor with the Army. And of course, all of everything that I say is my own opinion. But I joined the Air Force shortly after September 11th. And actually, Dr. Irmall was one of my first supervisors in turn ever. And definitely the best supervisor ever. And so anything I say is probably because she corrupted me early on in my career. But I felt kind of like a patriotic draw when, after September 11th, I was a PhD student when that all happened. I had an uncle who had been a fighter pilot, flew at 15s and so growing up, I had a lot of exposure to the military and was always drawn to that. And then, while I was an undergrad and a grad student, I worked quite a bit with local law enforcement. And just I've always felt a connection to kind of the first responder military type of people because they have a unique set of, set of stresses that they go through. And that goes way back to when I was an undergrad student and really felt a passion for working with that type of population. So to join the Air Force, had a great time, active duty, and too many stories, too many good things to talk about when it comes to that. But got to do a deployment to Afghanistan during that time. I became a reservist, meaning that weekend warrior where you do one week and a month, two weeks a year with occasional deployments after I finished my four years of active duty. Like I mentioned, I did the deployment where I got to fly all over Afghanistan and really see some of the stresses that our soldiers, sailors, Marine and Airmen are faced with when they're in a combat zone. And one of the highlights of my career actually was to do that. Came back and I spent probably close to a decade working in programs and research service where we did a lot of research on military and service members and how to maximize benefits for treatment. Following that, I did a couple little stints where I was, again, all this is a civilian working for particular army units. And as I was mentioned, I did a stint working for CDP as one of the army internship sites. And in fact, during my whole time working as an army civilian, I've almost always taught a couple of classes or been on faculty at the internship sites teaching a baby army psychologist in this passion I have for teaching. Later I transferred to the army reserves and I've done another deployment to the Middle East since then. And so I've been able to see the way that the military has changed and the nature of deployments have changed from the early 2000s to the late 2000s. And presently I work as a psychologist within an army unit. And so day-to-day I'm getting questions and dealing with the long aftermath and even the ongoing kind of struggles that people have with their military service. And then dialing back even further, Dr. Holloway and I went to a program together for our Ph.D. program that had a strong focus on psychotherapy research. But in a little bit of an unusual way because most psychotherapy research that you all hear about is apparently supported treatment. So a specific treatment for specific diagnosis such as cognitive behavioral therapy for insomnia. But there is a branch of psychotherapy research that's focused on general factors. And so I've been exposed to that all the way back in grad school. And I think that's what we'll talk about today. Yeah. It's my long story. And such relevant experience, I think it's really cool for people to hear that because you've got a long experience working with the types of people, with the types of populations that a lot of people who I think listen to this podcast have. But also relevant from the teaching side of things for EBPs and for psychotherapy in general. I mean, it's one of the reasons we really wanted to invite you to participate in the conversation today. Because just to orient our listeners, one of the things that we like to do in the podcast is think about questions that people ask us during workshops and kind of the issues that they'll bring up. And I think one that I've heard a lot and perhaps you all have heard too, is as we're talking about, as we're teaching a protocol, for example, for specific treatment, for specific disorder. The question comes up quite a bit of like, well, how do common factors fit into this? And I think it's a really important question for us to talk about, you know, that is psychotherapy nothing more than a checklist that we run down and check all the boxes or where do these other things fit in. So I don't know. As we're just as we're kind of getting started with that, I don't know, that's maybe kind of orient people into what we're talking about when we mean common factors. Like what common factors are we even, you know, referring to? What are these common factors? That's a great question. And how common are they? Right. Yeah, it's like common sense, right? Well, I'll tell you, I think when people ask that question, the one that immediately comes to mind is therapeutic alliance, right? That relationship and the importance of that relationship. And I think that's an important piece of this. So maybe we can start there. Yeah. Yeah. And maybe I'll just run through a lot of the common factors are stuff that are alliance-based and things such as, you know, having accurate empathy that the therapist is able to communicate and understanding that the client can feel that from them, alliance, and that sometimes gets into things such as collaboration and consensus that both people feel like they're working toward a common goal and, you know, that's part of that alliance. And then some of the traditional Rosary and types of stuff, such as, you know, that positive regard, that affirmation, that the therapist is communicating that you are a good human who is trying their best, you know, congruence and genuineness when the therapist makes a statement or makes a comment that it feels genuine and not faked. So those are generally what are thought of as the common factors. So, and so related to that, I think, you know, the sense that I get sometimes when people ask us is that, you know, I was always taught, for example, I may be speaking in their voice, I was always taught that common factors pretty much account for all of the change that we see in psychotherapy. And so if we focus on common factors and we don't need all this other stuff, why do we even need, you know, the CBT for insomnia, for example, why do we need act, why do we need any of these protocols or these approaches if we've got common factors on board? Yeah. And that's a good question and I, if I can pull a CBT term, I think that maybe sometimes displays our tendency for black and white thinking that it must be one or the other that we cannot have that somehow common factors do not exist, do not coexist with specific treatments. And I think that that often, so, I mean, if you go back into the origin of the common factors research, and this goes back to the 1930s, but basically they were starting to do review articles that were comparing treatments head to head and they were starting to see that a lot of these treatments kind of had equal success. So if you were looking at some of the interpersonal treatments or a brief dynamic treatment that they were having, you know, close to equivalent success as other treatments. And that's really what prompted the, you know, often the joke is the dodo bird verdict, which is the scene from from Alice in Wonderland where the dodo bird proposes a race and they all run around in a circle until, until they get dry. And then they're like, well, who won and the dodo bird says, everybody won and everyone must have prizes in some famous paper in psychotherapy research. But if it prompted this idea of like, well, if we are seeing a lot of overlap and success between the different treatments, what, what are the, why is that? And I think that's actually a prompt in the common factors research. But I think if it's like, hey, common factors account for a large proportion of the change. I think that's, that's maybe, I think sometimes I think I, Dr. Holloway, I think, I think what I see is, is two pieces, one is people think all common factors is like empathy. It's just the, it's just the, hey, how are you doing? It's the, I always joke it's the huggy, huggy, once I start, right? Yeah. And I think, you know, if you really dig into what, what is alliance and what is this idea of full consensus and collaboration, I think that's maybe where people aren't, aren't necessarily thinking about that when they, when they talk about common factors and, and how, having, having a goal can, can really is, is part of the common factors. And so, working with people towards specific outcomes, such as, you know, reducing insomnia, or, you know, reducing the number of nightmares, like that's, that is, are, that, like that has been kind of subsumed into the common factors research as well. Well, and I think sometimes the fear may, maybe the question comes from fear that I'm going to have to give up these great things that I know work with lots of my clients if I take on this sort of more rigid protocol that's an EVP instead of seeing the EVP as the structure, you know, sort of the scaffolding to hang these other, you know, the common factors on, like you can't do one without the other and you have to have balance between the two and see the similarities. Um, and, and so that, that's almost where I sometimes feel like the question comes from, like, but wait, you know, isn't, isn't as all this other stuff and, and, and how do I keep that and do this protocol and what, what's your experience with that? Yeah. And I think that is that, I mean, we're kind of like getting to the end of the podcast at, right at the beginning, but I, I do think that is, for me, that's what, what the answer has been. Like if I see someone, back when I was training students, if I see a student going in there and they're, they're cold and robotic and they're like reading out of the manual and I did the same thing. Dr. remote probably remembers me doing the same thing. No comment. Um, you're always warm and approachable. I don't know where to talk about that. And it's okay that we, we, we can go by first names on this podcast, we're really relaxed. Sorry. I don't want to take away from your, uh, all of your training and status that you have. Remember, I told you, always call me Dr. Um, always, always, always it stuck with me. Um, yeah, so I, I think that's often where I go and if I'm seeing that, that student who is, who is, um, jumping in there and they're, they're reading that script and they're, very diligent. They're trying to go through. Okay. Session one is, is this a session, you know, session one of, of prolonged exposure is taking a detailed trauma history and they're going through, right? Yeah. Yeah. Exactly. Exactly. Um, but that earnestness sometimes they becomes, um, you know, throwing the baby out with the bath water. They're so focused on, uh, on the, the rigid technical aspects that they forget that this is a human endeavor, like, this is, this is an interpersonal process that we're going through. And, uh, there, there's a reason that people work with a therapist and a counselor. It's, it's a, it's a human interaction and there's power and it's, there's power in, um, in that, in that interpersonal, uh, interaction to the point of if you don't, if they don't feel that, that affirmation, that alliance and that, um, that positive regard, it really doesn't matter how skillful your, your exposure treatment is, if they're not, if they don't feel like you understand, uh, and communicate an accurate empathy of how it is. So I, I always come off the top rope when I see a student robotic because, because, you know, because you only got someone to be more warm is, is always the right way to go. Just one of the challenging aspects of it, you know, as I'm thinking about these common factors and, you know, being a human with another human in the room is, is that sense of vulnerability. You know, we, we talk about common factors as this variable that's important to pay attention to and we kind of gloss over it, but it's also a little bit fuzzy and it has a lot to do with this. I mean, you have to be vulnerable as a therapist. You got to be a human being in the room with that other human being. And as we're kind of talking about sticking to the protocol and focusing on technique and being in that role of expert, I think there is kind of that danger that the more expertise you have or the more you're trying to stick with the protocol. And, you know, we've been talking about trainees, but I mean, you know, this also happens with season professionals too. You can almost double down on it. Like if you notice, there's sort of something with the alliance. You can sort of double down on, well, I got it be even more technically correct and follow the protocol better, which actually maybe makes that connection worse. So I guess that's something just to sort of notice, there's a lot to track when you're doing EVP. And one of the things to track is the quality of your connection with the client. Yeah. Yeah. Absolutely. I have a great story for this. I was working with a combat veteran who had some pretty substantial PTSD. He was brought to me because he had become pretty intoxicated one evening and started to say things, you know, that really worried his buddies. He kind of came to me unwillingly, was kind of forced in that way. And I was a very young and kind of therapist, I'm like, all right, PTSD, we're going to do exposure treatment. Because I do believe in the power of exposure treatments for PTSD, even as someone who deeply, deeply believes in the power of common factors. So I jumped in with the exposure treatment and we were kind of going along and like nothing's happening. And I'm, you know, it took me probably toward the end of the session and I was, I'm just like, hey, man, like this doesn't seem to, we're not seem to be connecting on this. And then he said, well, my dad was a psychologist and my jaw dropped and I just had a human moment where I laughed. And I'm like, oh, my God, I'm so sorry, man. I don't even, like, I can't even match what my kids are going to have to go there. It's a pretty little at that point. And then he laughed and it really was this kind of human connection moment. And where I had empathy, right, like I saw that he would, in that moment, I caught on that he was, he was very wary of me, probably related to, you know, some stuff with how he grew up and having a dad that was always in his business, just like, I'm in my kids business. And so I kind of laughed and said, yeah, I'm sorry about that. That sounds awful. And then he laughed and we connected and we actually had a very, very great work in relationship out of that. And we're able to do some successful exposure types of treatment that I don't think would have happened without me having that kind of working on the empathy in that positive regard now. And I think just your, I love that example. And, you know, in that moment, how you are spontaneously human. And I think that's also one of the challenges, I think, in training clinicians and working on, becoming, you know, working on the common factors is a lot of it has to do with those spontaneous moments. How do you, how do you train spontaneity, you know, without it seeming really stilted, right? How do you manualize spontaneity? Yeah. Like, what's the checklist? I haven't read, I haven't read that research yet. I'm not sure. You should write that up. It's all you, Andy, this is, yeah, you have your marching orders. Yeah. No interest in that. You know, it's just, it's one of those things that's, I think, tricky and one of the reasons that common factors just sort of gets put in this box of, yeah, this is an important therapist need to have that accounts for a lot of the variance, but like, make sure you do that. Soon, you've got it, you know, but getting into that, the nitty-gritty of what actually happened in that moment that you talked about, it's, it's, it's harder. I think I don't know if our models that we work from really give us a way of adequately, sort of talking about that and conceptualizing it in a way that doesn't reduce it down to rules to follow or steps that you have to, you know, go through every time. Yeah, that's a great point. I know Kevin and I, you know, we went to a program that was kind of like Yugoslavia, right? Every different, every different professor had a very, very strong feeling about what therapy should look like. So we had like a, like a no kidding, David Burns, Trains, you know, CBT professor, and we had, and we had like a, like third generation Rosyrian train person, and we had like interpersonal individuals, and we had, we had psychodynamic professors and one or two that were very well known group therapy researchers as well. And like I feel pretty, pretty lucky that I had that experience because I, I think back to one of my professors, Kevin, you might remember this, this story. She was, she was a psychodynamic and group therapist, and she was showing videos of her doing group therapy, and in this group therapy moment, her stomach grumbled. And she, one of the group participants tried to, tried to be motherly, to kind of jump into a little bit of psychodynamics, which was her style, and she said, oh, you know, are you hungry? And she said, no, I'm, I'm nervous. I really want to be able to make this point right now, and this is a tense situation. And, and so to have some of that, have a little bit of the interpersonal and dynamic training, I think that often they had a little more of that language for how to, how to, how to work through and understand your own, your own feelings, as you were doing therapy, to me, has been really valuable. And like, I had a guy come in just, just two days ago, who, who I've known him for about four years, ever since I started working in this particular place. And he's, he's kind of having the, the start of some panic attacks in a certain training situation, starting to hyperventilate, feel kind of the constriction in everything, and probably not, not quite diagnostic, but certainly a pro-dromal. And that's the right word for panic attacks. And he and I had a long, we have a long history together. And so we went right to, to developing an exposure hierarchy. So like, I'm like, I'm all about exposure treatments, and we went through and we found like, hey, here's, here's the worst, here's, here's a, here's a zero, there's one, two, three, four, five. And like, okay, hey, we're at a five. And for you, you're going to, you're going to put on your helmet and your, your, your, your, your, your flak vest, and you're going to go run out in the heat. And that's going to recreate this pressure sensation for you in a way that you can desensitize. But without like the consequences of an eight or not, right, so standard, like, panic treatment. And I didn't even have any kind of alliance because it was already there. But I think I think if you'd ignore, if you're not, making sure that the, that the alliance is primary, that can go really south. I think that's going back to something that came up earlier. I think that's, you know, one of the things that people get concerned about when they come to an EVP workshop or consider implementing EVPs in their practice, there's that fear of, I have to put down everything that I've developed or learned before, right? Like, I, like, I have to switch gears and do something different. And that's, that's not necessarily a case. It's you, you build, you know, kind of these protocols, if you will, or, you know, on top of the processes that are there already or that, that work to be human and to have that real interaction with the person. And then you, you build on top of that by helping them perhaps engage in, you know, kind of behaviors or, or the work that you would do to address some of their particular issues. But, you know, not getting rid of what you've, what you've developed in the past, something that's, you know, really valuable, you're, you're adding to it. Yeah, yeah, right. There's a fear like, oh, well, if it's all common factors, all I have to do is when this guy walks in and say, oh, that's not, yeah, I'm like, I'm creating a straw man of what common factors are. But, you know, oh, you know, that sounds really rough and horrible and that that's going to have the same outcome. And I will say that even, even within the common factors research, there is, there is room. Like, some of the more advanced research shows that there are some treatment differences and some of the treatment differences become pretty pronounced when you're talking about the anxiety disorders too. So I think, I, and I remember, you know, Kevin, our professor said like, if you're not doing exposure treatment for panic disorder, you're probably, you're probably in the wrong. And that's from a, a true blue Rosary and therapist. So, yeah, I, I think so. I think the opposite is also something that people get concerned about too. Like, they feel like, you know, therapeutic alliance and other common factors are so important. And so essential to the process that you just spend months and months and months and months building up alliance before we do anything else. I was actually going to, I was actually going to say, Michael worked in primary care when I was going to hurt him back to that experience, similar to what you're saying, Kevin, that's a, you know, that's a setting where you got to jump in fast, right? You don't have time and you have to figure out ways to build a alliance super quickly. And I think, given what Kevin's saying, that that's a, that's a mistake. Lots of people want to spend all this time building up this, this therapeutic alliance. You know, comment, just, I guess comment on that your experience in, in, is that necessary or how can you do that in a setting like primary care or sort of quickly when you have to be able to get that engagement and, and move on to, you know, kind of the shared goals and the treatment planning and what you're doing. Yeah. Now, I, I, I didn't even add to that, you know, I was, I was complementing like my, you know, the, the, uh, all the different professors I had, but, you know, primary care work is an excellent example of that. And I still remember the script that Dr. Irmo, that Jenna taught me, you know, snap shot. You know, she said, there's one word you must say, um, it's snapshot. Any, well, what's not going so well. That's right. And you would develop a little bit of a script and, uh, but the, like if you're, you're watching to see if you have that, if you're able to, to engage with them quickly and develop that consensus and collaboration, remember, remember, comment factors are not just about the warm fuzzy feelings, it's about, uh, people getting on board with, with, with the program. And they, they feeling like they trust you and that you are understanding them. And, and if you can develop that quickly, especially for very focused, uh, focused problems, like you can get going rapidly. Um, I remember Kevin and I were in, we were in school. Uh, there was, uh, we had a, a brief psych, a psychotherapy, uh, expert come and speak with us and, and he had to practice and, and they'd done some research on it. And, uh, I remember, uh, one of the comments from, from the research team was like, this dude is really good. I don't think they said, dude, because I'm the California guy, but they said, you know, this, this professor, this doctor is really, really good at rapidly developing, um, developing the relationship. I think that's, that's a really important point that, you know, this isn't like a, now we're going to develop the relationship, now we're going to do a protocol kind of a thing like this is all happening at the same time. And those, you, you've referenced this a couple of times, but the common factors isn't just that warm fuzzy feeling or it's not just that, you know, the unconditional positive regard. It's one of them, right? But even the idea of having, like you said, setting goals or having realistic expectations for outcome or, you know, talking about, you know, even some psychoeducation around what they're, they're experiencing all of that stuff can be part of building the alliance too and having that real human interaction, that real human relationship and connection while doing those things, I'll contribute to that. Yeah, absolutely. Um, and there's lots of ways to do that. And there's some really good books out there, um, like a heart and soul change, the Lambert book. I'm trying to remember the one by Scott Miller that also talks about it and, uh, I've, I've actually, I've gone and done some, some therapy myself and I remember one particular session where, um, where the, the, the doc, uh, I, I didn't feel was kind of hearing me very well. Um, I felt like, uh, like she kind of had her own agenda of what she believed I should think and feel. Um, and, and I was being a nice guy because that's what I do. And I didn't, I didn't say anything. And at the end, uh, she gave me an outcome measure. And I think it's, I think it's the Scott Miller one. It's like the four item outcome, uh, measure. And, uh, and one of them was one of the questions was, do you feel like, uh, like the therapist understood you today? And I, I put no. And, uh, and we had a conversation about it. Um, and, uh, you know, that's like, like, and, and that, that was a, that was her taking care of ensuring that the common factors were present, uh, with, with me, uh, even, even though she had a very specific treatment model that she was working on. That's kind of the second example of like, you know, almost when, and, and I mean, a mistake, but, you know, that story you told earlier about, you kind of looking up and saying, like, hey man, this doesn't seem like it's working. And I think that's another, going back to what Andy said about vulnerability, um, you know, when things aren't going well, when you're not clicking and if, and if you don't stop in that moment and try to address it and, and that's almost what moves that alliance up, even faster versus just kind of like pushing on with the protocol or pushing on with the next objective. What the protocol police come and haul you away? Yes. No, I mean, that's a, it's a really good point of knowing when to, um, really attend to the relationship and, and you know, Andy is referred to alliance ruptures before like they tend to those things as they come up and, and recognize when it's okay to kind of pause whatever protocol or whatever, you know, checklist thing you were going to work through that day and really attend to that person in the room, that human in the room. Yeah. It reminds me a lot, it reminds me a lot of a conversation we had with, uh, Dr. Robin Walcer in a previous episode, um, talking about processes versus protocols that importance of focusing on the processes and, and those relationship pieces are part of those. I can't remember the term she used. Andy Dumer, this is like these little slices of behavior or these, yeah, that, uh, you are all part of what's going on in that room that we need to be attending to and not just are we checking the boxes in the right order and, you know, are the protocol police going to come take us away that kind of thing. So given all of that, Michael, and we appreciate you being here talking about the stuff with us. This is practical for your practice. We like to end any of our episodes with some actionable intel, things that practical tips that our listeners can take with them and implement, you know, today regarding these things. So with regards to common factors and, and how that interweaves with EBPs, any thoughts about that? Any tips for? Yeah. Yeah. I've got, I've got a couple. I wish I remember the name of the person that said this. He was a, he's a World War one corpsman and he said, uh, counting is an antidote to bias. And we, we fall in love with our, our treatment. We, we, we, we think we're doing great, which is where you want, you know, you want to think that you want to feel like you're competent. But the counting is a way to, to kind of understand where you're at. And so, like, you know, triple stomped the idea of doing some kind of outcome measure and it's funny. That's, that's some of the research that I, that's how it, what I did, my dissertation on was, was outcome measures at the end of therapy. And so I, I always believed in it. I saw the research that when, when you, when you have the, the patient fill out, um, measures of, of alliance, such as the outcome questionnaire or, uh, measures of, of their status and, and you see if they are getting improvement and getting better or worse and you can, you can talk to them about that, hey, it looks like you're actually feeling better. Like your symptoms seem to be going down. Like, that's, that's a way to demonstrate, uh, empathy and, and that you're working together. Um, or if you're using some of the, the, the Miller kinds of, um, post therapy assessments is four questions, um, those, those are great ways to, and I guess we'll link to them. Those are great ways to, to double check and that, that counting really can, can work quite well, um, the other thing that I, that I, that I love is, is kind of the, for chaska, declementate, trans, theoretical model of, of, you know, readiness for change and, and, uh, uh, for while it's kind of invoked to, to add that to your treatment planning to consider, hey, where is this person in their readiness for change? Are they, are they pre contemplative? Are they like, not even in a place where they, they, they, they should change or are they kind of contemplating it, but, but not really ready to, to pull the trigger or, are they? And that's, you know, contemplation and action or maintenance mode. So, uh, so, so, so adding a little bit of a consideration about, you know, where the person is, I think is all, all can be kind of subsumed in this idea of developing an alliance and being able to empathetic is that kind of what you are, what you're asking for. Thank you. I think that's fantastic. Those are just some great tips and, uh, suggestions for folks. Really appreciate you having on. It's always a good time talking with you and, uh, kind of both reminiscing, but also, you know, really kind of taking on some of these topics and, and wrestling with them a bit. So, that's pleasure, you know, anytime to tell a few stories and get a few laughs and I'm, I'm happy to do that. There's really good to have you on today. Thank you so much. Thanks for listening to practical for your practice. Please feel free to subscribe, rate, and join in on the conversation in the comments. Until next time.