The Heart & Soul of Change: Delivering What Works in Therapy

According to this second edition of the renowned Heart & Soul of Change, it’s time to move on from common factors vs. specific factors, and it’s time that arguments over the benefits of specific therapeutic approaches be put to bed forever. Is the field ready to move on?

Rating: 4

The Heart & Soul of Change: Delivering What Works in Therapy

Edited by , 2010. ISBN 9781433807091. American Psychological Association. 455 + xxix pages.

The first edition of this book was one of the best I’d encountered in the field. (See the lengthy review “Hubble, Duncan and Miller on What Works in Therapy”.) I was not alone in finding that first volume to be superlative: the book won the Menninger Foundation award for scientific writing, it became a bestseller for APA Books, and it was positively reviewed by clinicians and researchers alike. This all-new second edition has some rather large shoes to fill, a feat which it manages at least partially.

The first book translated a huge body of research on common factors into the stance, controversial in some corners of the field, that psychotherapeutic theories and their associated techniques have very little to do with therapeutic outcomes, highlighting instead the central role of factors common to all schools of psychotherapeutic thought. This second volume moves even further toward a unified view of “therapeutic factors” and argues against the common factor vs. specific factor distinction entirely. As the editors put it in their concluding chapter (p. 423):

Despite the precedent for their use, the words specific and common keep the profession bogged down in false distinctions and needless polemics. In the end, without doubt, it is not a matter of what therapies have in common. Instead, it is all about the factors that make therapy work, regardless of theory or orientation. The profession is and will be better served by attending to what are termed therapeutic factors.

The book’s editors treat this conclusion from the evidence as nearly unquestionable, and the banishing of arguments over theory and technique as essentially a fait accompli, commenting just before the text I quoted above that (p. 422):

…it can be affirmatively stated: Theoretical schools and the impassioned rivalry they nurtured for many years…have outlived whatever meaning or function they once provided. For the sake of our clients and our own progress, it is better to regard them as subjects for historians…doctrinaire declarations endorsing specificity have wilted under reasoned scrutiny and now are not at issue…

Except, um…they are at issue. They are still very much at issue.

Perhaps this is just a bit of concluding chapter showmanship, but in my view it highlights a significant shortcoming in the second edition which was absent from the first. And it is exactly on this point that I am at once 100% in agreement with the book’s premise and 100% skeptical that this case has truly been made, if this is really the case the editors wish to make.

A practitioner reading the first book couldn’t avoid coming away with either a fistful of arguments to buttress their own position that common factors and client variables were at the heart and soul of change, or a whole slew of incisive points to consider and reflect on in a way that could wind up challenging their own outlook on the field. A practitioner reading the second book? Well, not so much. To be sure, some critical arguments are still there, the evidence is still offered in abundance, but it seems to me that it’s exactly this presumption of victory — this assertion that the field has moved on and that those old arguments about techniques and individual therapeutic schools of thought are just so last century — that risks unanchoring the book from the reality of everyday practice. I say this both as someone who agrees with the move away from model-centric discourse and as someone who can see all around me the pervasive influence of EBP-riddled debate draining the “therapeutic factors” right out of the discussion.

Regardless of whether other readers also find themselves tripped up by this “battle over” transition, however, the book of course still has a great deal to offer. While it doesn’t quite come through with how to manage that feat alluded to in the subtitle — actually delivering what works in therapy — it goes a long way toward encouraging adaptations and modifications to existing practice that will help. For example, it highlights the role of ongoing feedback and outcome monitoring in improving effectiveness, and while this might seem almost obvious to many of us, it’s not so long ago that continually soliciting client feedback and checking on outcomes was rather far from central to how the field operates. The book also reminds us of just how much variance comes from competence — or lack thereof — on the part of practitioners, and it recommends large-scale data mining to try and identify more of the factors which contribute to individual practitioners’ effectiveness.

The success of the first book has provided a strong platform for this book to be heard and taken seriously: practitioners, researchers, those who pay for services, and policy makers are all going to start off inclined to pay attention to what this book has to say, simply because the first provided such a strong contribution to the field. Just as the first book very likely did much to help change therapeutic practice, thinking and teaching, this new edition has an opportunity to press ahead and develop the field even more.

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