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• W1804306999 abstract "We thank our colleagues for their thoughtful commentaries. Such discussion is what we hoped for in publishing this monograph. Bergmark 1 defends the continued use of the term ‘common factors’. It remains unclear just how common such factors like empathy actually are across treatments and providers. We hardily disagree that relational factors are ‘incidental’ in treatment theory, which instead should be expanded to include such factors. It is not either/or, but both/and. Hartmann-Boyce 2 defends meta-analytical aggregation of findings and worries that specifying ‘non-specific’ factors simply plants more trees. Happily, multivariate analyses have evolved far beyond those required for a horse race or an effect size. The challenge is to examine the simultaneous impact of specified factors within the context of other important factors. Meta-analyses should take into account intervention fidelity 3 and conditions with which treatments are compared 4. Magill 5 expands on the paucity of differences when specific therapies are compared with treatment as usual, the closest thing to a placebo control in psychotherapy research. She calls for better study of standard care, a different genre of research than testing specific therapy brands 6, challenging the field to develop methods that are sufficiently creative to model complex interactive processes. Bricker 7 wants to climb the trees for a better view. Linking therapy processes with outcome lies at the heart of ‘mechanisms of action’ studies already well advanced in addiction treatment 8, 9. Removing therapists from the equation through standardized delivery has been around for some time in ‘bibliotherapy’ research 10, 11, and more recently in computer- and web-based interventions that can reach larger populations 12, 13. This does not obviate contextual characteristics; specific aspects of delivery mode may still influence outcome 14. Similarly, cost-effectiveness research has a long history in addiction treatment 15, 16. Our field has over-relied on searching for superior specific treatment agents 5. A psychotherapy cannot be separated from the therapist (or even technology) delivering it. Testing specific hypotheses remains important, but a broader view is needed. Models including a wider range of relational and contextual factors could increase the amount of outcome variance accounted for, and may even be useful in pharmacotherapy research. Both medication and placebo are delivered by staff who interact with patients, and the effectiveness of placebo conditions can vary widely within a multi-site trial 17. Some ‘placebos’ are more effective than others, perhaps owing to relational and contextual factors that can affect the likelihood of finding a medication effect. Much is going on in treatment beyond the posited effect of any specific factor. Psychotherapies are complex, inseparable from provider and context. Manual-guided treatments may contain ‘active’ ingredients that promote change, irrelevant superstitious elements and even iatrogenic components that impede change. Providers vary in fidelity of the intended treatment and a host of relational factors 18. Treatment effectiveness is unlikely to advance much further by simply examining one tree at a time or comparing any two or three. Understanding the forest has, we think, been obscured by standing too close to the trees. None." @default.
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• W1804306999 date "2015-02-11" @default.
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• W1804306999 title "On having and eating cake" @default.
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• W1804306999 doi "https://doi.org/10.1111/add.12819" @default.
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