Cognitive Therapy and Research (2018) 42:212–217
Miles to Go Before We Sleep: Advancing the Understanding
of Psychotherapy by Modeling Complex Processes
· Robert J. DeRubeis
Published online: 3 February 2018
© Springer Science+Business Media, LLC, part of Springer Nature 2018
One of the main debates in the study of psychotherapy is whether speciﬁc techniques are best indicated for diﬀerent prob-
lems or whether “common factors” better account for the eﬃcacy of psychotherapy. Evidence for the superiority of speciﬁc
techniques is mixed and limited to a handful of diagnoses. By contrast, evidence for the importance of common factors is
riddled with methodological weaknesses and may be of limited clinical utility. The stagnation in this debate may reﬂect
that the research methods heretofore employed have reached a plateau in their ability to advance knowledge regarding psy-
chotherapy processes. The articles of the special issue move beyond simple bivariate relationship and attempt to model the
real-world complexity involved in the process of psychotherapy. It is argued that these types of investigations, which model
the interactions of patient characteristics as well as multiple speciﬁc and “common factors,” are the best way to advance the
state of knowledge regarding psychotherapy processes.
Keywords Psychotherapy processes · Psychotherapy outcome · Psychotherapy
The prototypical psychotherapy process article begins by
declaring that psychotherapy “works” while lamenting that
its mechanisms of change are not well-understood. The
articles on the Special Issue manage to avoid this conven-
tion, which is no small feat. More impressively, this series
of studies illustrate signiﬁcant advancements in psycho-
therapy research. The commonality of these studies is that
they attempt to model, theoretically or statistically, the real-
world complexity involved in the process of psychotherapy.
Another impressive commonality of the papers is that they
suggest actionable recommendations for clinicians.
Psychotherapy researchers can be arrayed along a dimen-
sion, which, at one extreme, features those who espouse
the importance of applying speciﬁc treatments and tech-
niques for diﬀerent diagnoses. These researchers usually
rely on evidence from randomized clinical trials (RCTs).
At the other extreme are those who propose a central role of
“common factors” as causal agents of change, with evidence
drawn primarily from correlational (process–outcome)
ﬁndings. Beyond supporting the superiority of cognitive-
behavioral therapies (CBTs) for bulimia/binge-eating and
sleep disorders (see DeRubeis and Lorenzo-Luaces 2016;
Hofmann and Barlow 2014), as well as the importance of
engaging feared stimuli in anxiety disorders (see Laska et al.
2014), the RCT literature does not support very speciﬁc or
helpful claims about how best to conduct psychotherapy. In
depression, arguably the disorder for which psychotherapy
has been most widely studied, evidence for diﬀerences in
outcome among these orientations is weak, though the qual-
ity of the evidence varies widely between schools of therapy
(Barth et al. 2013). Across disorders, a published meta-anal-
ysis found that the linear association between adherence to
speciﬁc elements of therapeutic orientations and outcomes
was small and not statistically signiﬁcant (Webb et al. 2010).
A subsequent unpublished meta-analysis (Soriano 2014) did
ﬁnd a relationship between adherence and outcome as well
as between competence and outcome. In the latter study,
these relationships appeared concentrated in studies of treat-
ments for substance use and for depression.
Research on common factors is somewhat more optimis-
tic in that it supports a robust bivariate association between
the therapeutic alliance and outcomes (Horvath et al. 2011).
* Lorenzo Lorenzo-Luaces
Department of Psychological and Brain Sciences, Indiana
University – Bloomington, 1101 E 10th St, Bloomington,
IN 47405, USA
Department of Psychology, University of Pennsylvania,
Philadelphia, PA, USA