The Power of Common Factors: Rethinking How We Train Psychotherapists

The Power of Common Factors: Rethinking How We Train Psychotherapists

For decades, psychotherapy training has focused on empirically supported treatments (ESTs). Yet with hundreds of modalities available, it’s simply impossible for any therapist—let alone a trainee—to master them all. Most clinicians leave training fluent in only one or two therapies, creating gaps in competence and confidence.

A growing body of research suggests a more effective path: teaching the common factors that drive outcomes across all therapeutic approaches as the bedrock for all therapies. These foundational elements shape the success of therapy far more than the specific model used, and they are essential to developing skilled, flexible, patient-centered clinicians.

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Six Common Factors That Shape Psychotherapy Outcomes

1. Patient Characteristics

Patient traits account for a substantial portion of outcomes—often more than the type of therapy itself. More than 160 patient characteristics influence progress, including motivation, readiness for change, cognitive complexity, and emotional resilience etc. Facilitating traits enhance engagement while inhibitory variables—such as personality disorders—may slow progress.

2. The Hawthorne Effect

Simply receiving focused attention can improve symptoms. The Hawthorne effect—symptom relief triggered by feeling noticed, heard, and cared for—may account for 10–20% of early therapeutic gains.

3. Hope and Positive Expectations

Positive expectations can contribute to one-third of therapy’s overall effectiveness.

Hope is not merely supportive—it’s an active ingredient in treatment, much like placebo mechanisms in medicine. Successful therapists cultivate realistic optimism from the first session.

4. The Therapeutic Alliance

The alliance—shared goals, agreed-upon tasks, and a trusting bond—is one of the strongest predictors of outcome. Depending on how it’s measured, the alliance accounts for 20–35% of the variance in patient improvement. Repairing alliance ruptures is just as essential as building the alliance.

5. Therapist Characteristics & Behaviors

More than 27 therapist variables correlate with outcomes. Empathy and mentalizing capacity have a medium to high effect size, and patient-rated empathy is a better predictor of success than therapists’ self-assessments. Genuineness, emotional intelligence, collaborative goal-setting, countertransference management, and flexibility all support better outcomes.

6. Extra-therapeutic Factors

Life events outside the therapy room often influence progress more than the therapy itself.

Positive life changes can accelerate improvement; negative events can complicate or halt progress. Skilled therapists anticipate these influences and integrate them into treatment planning.

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Educational Implications: Teaching What Really Matters

Centering psychotherapy education around common factors helps trainees develop broad, flexible competence. Instead of siloing themselves (early in their training) into specific models, clinicians learn to understand how therapy works and focus on the person in front of them.

A common-factors curriculum emphasizes:

• Patient-centered foundations before theoretical allegiance
• A shared language across therapeutic modalities
• Tailoring interventions to individual patient needs
• Teaching broad, integrative frameworks before technique-specific schools
• Introducing ESTs later, when fundamentals are in place

This mirrors how medical education is structured across specialties: fundamentals first, specialization second.

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Conclusion

Focusing on common factors is a powerful way to strengthen psychotherapy training and enhance clinical effectiveness. By teaching the elements shared across all therapies—patient engagement, alliance, empathy, expectations, and individualized care—we prepare clinicians who can meet the needs of diverse patients with confidence and competence.

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About the Author

Robert E. Feinstein, MD

Professor of Clinical Psychiatry, Zucker School of Medicine at Hofstra/Northwell

Psychiatrist, Psychoanalyst, Educator, and Supervisor Chief Medical Officer (former), Televero Health

Dr. Feinstein has devoted his career to integrating clinical expertise, research evidence, human understanding, and organizational leadership. He has designed psychiatric education programs, psychotherapy curricula, supervision models, and integrated-care systems across multiple states. His work spans medical and residency education, psychotherapy training, personality disorder treatment, emergency psychiatry, and telemental health innovation. He is the creator of Café Psychiatrique, a monthly educational series blending history, clinical expertise, and the humanities.