EXAMPLE ANSWERS: Q6

Q6. In a maximum of 1500 words, explain what is meant by the term extratherapeutic factors, how you would get to know about them from the client and suggest an example that may impact on the outcome of therapy.

Learning outcomes: 1.9

Student answer For the therapist it may be disappointing to realize that the majority of the ’magic’ of therapy can be attributed to factors other than the content of the therapy itself: Lambert (1992) attributes 40% of the outcome to extratherapeutic factors; 30% to relationship factors; 15% to expectancy and hope and a mere 15% to techniques and models of the approach. As the largest proportion of influence it is important to understand what is meant by extratheraptic factors; every human is a complex blend of ingredients which make them unique within this world. This is the joy of being human and no one person is exactly the same as any other. “The only thing that made me, or any of us, special was that no one in the whole of history would ever see the universe in exactly the same way any other of us saw it” Morrison G (2011) Within therapy this means that the response to every client and indeed within every session must be tailored to the unique individual who will be participating in it. So what factors are included? Although not a definitive list the following may have influence: the environment in which a client exists; what support they have; their inner strengths, abilities, and chance events (Hubble et al 1999). Even within this list there is variation reflecting the true individuality of a human – support for one person might mean family; to another a pet or a friend or any combination of all… For one person “Faith” may mean a religious creed, for another a set of values to live by. Every experience – positive or negative; past or present; real or imagined - has made the person who they are and influences how they will respond to life let alone any interventions. Before commencing therapy, metaquestioning and the creation of the therapeutic contract will elicit some of these factors. It is essential that attention is paid to what is both said and unsaid; a client may express an outcome they believe they desire only for fears or beliefs to create an unconscious sabotage. Asking ‘around’ a subject to see if there are different responses, checking your understanding is correct, asking what a term which is used means to an individual are all techniques which may assist. A client’s honestly held belief should not be directly challenged but finding out if the stated anticipated outcome is congruent with the clients life is an important factor. “Do not free a camel of the burden of a hump; you may be freeing him from being a camel” GK Chesterton An example from my own practice was working with a female client who wanted to “stand up for herself better”. Firstly we examined what ‘better’ meant to her – how would this be seen, experienced – how would she feel if she stood up for herself “better”? This produced some interesting results – she was often perceived as aggressive when she did stand up for herself and then felt very sad and angry with herself afterwards. However ‘better’ was also linked for her with dominance, ‘winning’ an argument and being heard. She worked in an environment in which there was a culture of competition and challenging dominance. Further questioning elicited some interesting confounding variables. Her upbringing had produced some beliefs that women should not be assertive – they should be subservient to men, to elders and to ‘her betters’. She feared being called ‘manly’ which she associated with being dominant in a conversation. On a conscious level she felt strongly that she “should” be able to be an equal in any conversation and assert her opinion but at the same time subconsciously she felt this was disrespectful and rude – not being rude was extremely important as a value for her. Often she overcompensated especially if she felt she was being talked ‘over’ or was asked not to shout and therefore was perceived as even more aggressive. She also still lived at home with her parents and was experiencing conflict with respect and the balance of being an adult. We concluded that the work needed to focus on how she felt when she wanted to make a point – being calm, with a normal voice tone and feelings of being able and entitled to make a valid point. This example illustrates the power of the subconscious and the extratheraputic factors which needed to be considered. In this case these included gender, upbringing, age, personal and family expectations and her job role. (LO 1.9 An understanding of the nature and impact of extratherapeutic factors)

Further example Student Answer:    Extratherapeutic factors are other elements of the client’s character and their issues that are brought to the therapy session, such as life experience, their knowledge (which includes knowledge of therapies) their strengths and fears etc. their willingness to participate in the therapy. An older person is not necessarily wiser or mentally stronger than a younger person, a more informative factor would potentially be a greater experience of life. Also someone who is afraid of losing control will require a different style of induction from a somnambulist.

This can also include hidden issues even the client may not fully realise they have such as nail biting due to past stresses. A client may present with a lack of motivation only for meta-questioning to expose a fear of success as a deeper issue. Some fears may be illogical to the client and possibly even the therapist and as such the therapist must recognise and take into account such fears during the session.

A detailed and thorough Meta-questioning will help to identify such areas of concern and their meaning to the client allowing a more productive intervention to take place. If the meta-questioning is not sufficiently deep enough or the client evasive / refuses to divulge information relevant to the issues then the outcome of the session will be unsuccessful in most occasions as the root of the problem needs to be dealt with or it will either return or produce different symptoms neither outcome is helpful to the client or the therapist.

Q6. RESUBMIT PLEASE

The first two parts of Q6 are correct, however please elaborate on the example that may impact on the outcome of therapy. With the nail-biting issue that you have offered as an example, specifically which metaquestions would you ask in order to expose the fear of success?

n-depth meta-questioning should reveal the true thought process behind a clients actions even if they do not consciously know themselves. They state they are lacking in motivation for a project but later reveal they actually fear successfully completing a project, as they would then have to deal with other issues such as praise, recognition or promotion and more responsibility.

A person may state they want to stop biting their nails when stressed, on basic questioning they might offer a reason of they have always done so or they don’t think about it, offering that it just happens.

On deeper questioning the true nature of the habit may be revealed to be they consider only beauty obsessed people would have nice nails and they do not consider deep down they are worthy, or they are putting their fingers to their mouth to stop them saying something they feel they shouldn’t at the time of being stressed such as telling someone off or swearing etc.

My line of questioning would (obviously dependant on their individual response to each question) be along the lines of:-

Was there a time when you didn’t bite your nails?

Can you remember the first time you started to bite your nails? (possibly using regression to establish the trigger)

What do you feel when you notice you’re biting your nails?

How do you feel when you are biting them?

“But if you did know the answer, what would it be the reason?”

or

When you look at your nails what do you see?

How does that feel?

If you were to have nice nails what would that mean to you?

And how would that feel?

The particular client with nail biting issues was a young quite attractive female in a fairly pressurised job complained of poor nails, blaming stress as the cause, on questioning she eventually revealed she didn’t want to be perfect (pretty, nice hair, figure AND nice hands) as she might lose some friends, so to remain flawed she would keep her hair fairly plain (required for work anyway) wear baggy clothes and bite her nails and the skin around them to have ‘horrible’ fingers…

To proceed with a particular direction of therapeutic suggestions to stop her biting her nails would be difficult as her sub conscious desire not to be “perfect” would fight any suggestions to stop the stress biting and grow beautiful nails and take pride in her fingers etc. By establishing the thought processes and root cause, the therapist could work on the real issues and thus the session would become more successful.

This particular client has had an initial consultation to discover the issues but she acknowledges the root issues isn’t ready yet to move forward from this position but has promised one day she will visit for therapy to release her fear.

Thank you for this resubmission Bob and it is very useful to acknowledge the approach and success you have had with this particular client and the revelation of the reasoning’s behind such behaviour. A thorough, specific and unique answer.