HOME QUESTIONS: The ADVANCED 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

Advanced clinical knowledge and skills1.9 An understanding of the nature and impact of extratherapeutic factors.

EXAMPLE ANSWER AND ASSISTANCE

Q6

Note length of required answer and learning outcome

Extratherapeutic Factors – Explain Term

Information gathering from client – Explain How

Suggest example of such that may affect therapeutic outcome

Example Answer from student, “The term “Extra-therapeutic factors” refers mainly to that which exists previous to and outside of the therapeutic scenario, those such factors that accompany the client to therapy. These elements include the client's own strengths / weaknesses, their abilities, any specific fears, their faith and personal beliefs, also their life experiences and their commitment and readiness to really change.

Many other influences may be bearing upon the client, these can include all the circumstances of their home and working environment, their partner and other loved ones, and how much or how little support they receive. It is estimated that approximately 40% of change is attributable to client 'extra-therapeutic factors'. (Miller et-al: 1997).

The existence and substance of such extra-therapeutic factors may be elicited by careful meta-questioning, bearing in mind that each client is unique and they will have obtained their own world view which is, to them, perfectly reasonable. Care should be taken to avoid directly challenging or refuting the client's position, while guiding them to accept that further choices are available to them.

For a particular presenting problem, possibly an irrational fear, or an aversion to something innocuous, the therapist might decide that 'past life regression' is an appropriate course to take. However, the client may be of a particular religion or belief that forbids or distrusts any such thoughts regarding previous lives. Such a conflict could result in the client “surfacing” from the state prematurely, becoming upset, and no longer trusting the therapist.

Another example where 'extra-therapeutic factors' could affect the outcome of the therapy could be a client that is supported and encouraged in making the desired change by those close to them. Conversely, derision of or obstruction to the desired change by the client's peers may be expected to impact badly upon the outcome.

A client that wishes to stop smoking may be surrounded at home and work by chain-smokers, or they may have lost someone close to them as a direct result of smoking. Discovering such factors as these are useful to the therapist, allowing the tailoring of suggestions to suit, and may impact greatly upon a successful outcome.”

Q6. Correct. You have understood the question well and have given a good example of how a belief system may impact upon therapy.


Example Answer from student:  Extratherapeutic factors are the elements which exist within the client, and therefore brought into the therapeutic setting. The clients ‘map of the world’ determines them. Every person will have a unique map of the world based upon the way in which they process and filter information from the world around them, through deletion, distortion and generalisation.

Extratherapeutic factors, which of course will vary from client to client, include, the client’s past life experiences, knowledge, beliefs and values, strengths, abilities, fears, support network, readiness to change, and personal circumstances, i.e. relationships, family, home and work environment, friends etc. According to Scott D Miller and Barry Duncan (Talking Cure.com) when discussing the factors in bringing change in therapy they state that ‘extra-therapeutic factors – 40%’. Therefore, it is evidential that if these influences are overlooked or not dealt with appropriately, any therapy is unlikely to be effective.

Sprenkle and Blow (2004) reported that client factors are the characteristics of personality of the client. Extra-therapeutic factors are components in the life and environment of the client that affect the occurrence of change, such as the client’s inner strengths, support system, environment, and chance events. More specific examples of these factors include faith, persistence, supportive family members, community involvement, job, or a crisis situation (Hubble et al., 1999). (The Contributing Factors of Change in a Therapeutic Process. Michelle L. Thomas)

In order to determine the client’s unique extratherapeutic factors, careful meta-questioning is important. On meeting the client, some basic information could be acquired during the rapport building stage, which would likely be viewed as general chat to the client, but which gives the therapist an insight into some of the client’s circumstances, such as general questions about work (have you come here straight from work?) or family, maybe their partner dropped them off. These are all clues into their personal circumstances, which the therapist can gain insight from by noticing the client’s unconscious communication whilst discussing them.

The rapport build would naturally lead onto meta-questioning, once an appropriate level of trust has been created. The questioning needs to be done carefully, in order to obtain the required information to build a picture of the client’s extratherapeutic factors, whilst remembering that the clients ‘map of the world’ is unique to them. It would be disastrous to the therapy to show any signs of revoke or dismissal towards the importance of their beliefs and values etc. as these will be ‘normal’ and real to the client, even when this may be difficult for the therapist to comprehend. For example, the client may be very superstitious, where the therapist is not. The client may feel great anxiety at seeing a single magpie, where the therapist would never even give it a second thought, therefore, without realising the importance of accepting that everyone views the world differently they may be inclined to dismiss the issue as something trivial, when to the client it is huge. Therefore, it is important to meet the client where they are, showing empathy and understanding even if the therapist does not agree. To fail to do this would risk losing rapport and damaging the therapeutic relationship.

Once the extratherapeutic factors have been determined and the therapist has acknowledged and shown respect of them, the client can then be gently lead into realising that there are other choices available to them. The therapist can now encourage them to open up to new ideas and ways of thinking, maybe by referring to past experiences where they have changed their way of thinking and behaviour which has brought about positive change, or by using a story of a client in a similar position (real or fictitious) who made positive changes by making other choices available, which they never would have thought about before.

As I mentioned earlier, extratherapeutic factors can impact upon the therapeutic outcome greatly, in various ways. If the client felt that their problem was huge and because of past experiences, believed that an issue as complex as theirs would take a large amount of therapy time, yet the therapist claimed that the issue could be dealt with in a couple of sessions, the client would likely mistrust the therapist, being suspicious of them failing to understand the complexity and severity of the problem. In this case, the client would be likely to terminate the therapy all together or sabotage it, claiming that it didn’t work for them, as they feel that the treatment was too quick to ‘cure’ the issue. If extratherapeutic factors are not recognised and taken into consideration, it can result in the client terminating the therapy, therapy taking longer and being more complex, the failure of gaining desired outcome or the client experiencing a recurrence of symptoms after it appeared the therapy had been effective for a period of time.

An example of the range and complexity of extratherapeutic factors and how they can affect therapy can be demonstrated here. A middle aged woman comes for therapy to help her to gain control over her weight. After years of fad diets and her weight yo-yoing she feels at a loss as to what to do next. All of the women in her family have been, and remain overweight and have constantly told her that she will never lose weight and keep it off as ‘it run’s in the family’.

She now holds the belief that there is a strong biological connection to her own weight issues and those of her family. After further questioning it becomes clear that she also holds fear about losing weight. Her family interactions are largely connected to food, and she feels that if she is slim she will no longer fit in with her family, fearing that if she is to maintain her new healthier weight, she will be forced to forfeit some of the family gatherings so she doesn’t eat too much and therefore miss out of socializing with her family and may drift away from them. When asked how these interactions with family make her feel, she admits that they bring her much enjoyment and comfort.

We can see from this example how various extratherapeutic factors are present here and can have a huge impact of the success of therapy. Her past experiences tell her that she will fail, as she has done in the past and as her female family members are constantly telling her, therefore leaving her with little support, on the contrary, bombarding her with negative views. Her desire to ‘fit in’ or conform to the ‘norm’ causes her angst, as she fears that if she is slim in a family of overweight women, she will be classed as being different, or an outsider, having less in common with her much loved family.

Her beliefs about the physical link is likely causing her to procrastinate in the view of ‘dieting’ being futile if she is destined to remain overweight anyway. She is also likely to have strong associations regarding food. She has learned that food means enjoyable, comforting experiences with her loved ones, which, as shown by her fear of the loss of this, she views as being a very large and positive part of her life.

All of these factors would need to be addressed before a successful outcome could be achieved. Though, they would need to be acknowledged as being important to the client first, or there is a danger that she would feel that she hasn’t been heard or her beliefs had been discounted. The therapist could then begin to encourage her to open her field of thinking in order to encourage new ideas and ways of dealing with the issues whilst assessing her readiness to change.

Tutor feedback (DO NOT delete/edit feedback. Write amendments, additional information & thoughts underneath this table)

Correct. You have clearly understood these factors and this goes towards making you the excellent therapist I have witnessed. Your ability to pick up on certain issues which would escape others is so valuable. Your linking of the weight control client to family issues and environment factors is very valid. You have obviously had a lot of experience already in this area and I hope more and more clients receive the benefit of seeing you. Thank you also for the referencing to other sources. A fully comprehensive answer, thank you. 

Example Student Answer:  The term "Extra-therapeutic factors" refers to any additional significant and relevant external motivations, variables and efforts which are activated and maintained by the client in direct alignment with their therapeutic goals outside of the space of therapy. These factors include the personal qualities of the clients individual character, characteristics, strengths/ undiscovered strengths, untapped potentials, morals, ethics and systems of faith and reality. 

Therefore an example would be client A holds within his persona, the qualities of discipline, vigilance, patience and leadership and through his belief system and training as a soldier he has developed a natural ability to harness and direct focused and clear thought processes to attain his goals. When working within the therapeutic space, with knowledge of this, the therapist can utilise these qualities to enhance progress by activating these qualities and aligning the client with them in the framework of therapy. Ultimately it's similar to the art movement of ready-made and found items, we simply utilise what's already available and change the context.

It is the therapists priority to establish a high standard of natural rapport in order to gain trust and understanding from the client, if there is a substantial lack of fundamental cohesion or authentic empathy then there will be an inherent struggle within the therapeutic space and this creates barriers. In order to dismantle such barriers meta questioning is the key to the process of information gathering, therefore the questions asked in the first 30 minutes within meeting an individual are enough to allow both parties enough time to recognise if there is potential for healing or if another therapist would be better suited. If within the initial consultation space, enough relevant extra therapeutic information can be gathered the progress can be made, as the therapist can design an accurate and workable scenario of reality as the client knows it.

An example would involve:

Client B comes to me, and states that she no longer wants to smoke, and she mentions that she is a horse rider, then I would use the qualities, drive and inspiration drawn from that hobby to inspire a change in habitual thinking in regards to stopping smoking, so I'd utilise the feelings that she feels when she's lost and happy riding her horse, and using that language as a metaphor I would then change the context to fit her wish to stop with the smokes. So there would be a sense of familiarity in the suggestions I used that were inherently meaningful to her so her mind and soul would understand easily and adjust accordingly.

 

Tutor feedback (DO NOT delete/edit feedback. Write amendments, additional information & thoughts underneath this table)

Correct. I enjoyed your example here and your linking to the horse riding with regard to a therapeutic intervention is a good case in point further demonstrating your comprehensive appreciation of these factors and impact on outcome.  

Example Student Answer:  There are different factors that are common to all therapeutic intervention including hypnotherapy. Extratherapeutic factors account for up to 40% of the desired outcome according to Miller et al (1997) and are made up of the factors in the clients own environment outside of the therapeutic relationship- “knowledge base, life experiences strengths and abilities and readiness to change” (https://secure2.ewashtenaw.org/hosting/Professional_Development/WCHO/z-COD%20web%20modules/definitions/def_pages/e/extra-therapeutic_factors.html). In the book from 2000, ‘The Heroic Client’ Miller and Duncan encourage the therapist to put their clients into the role of “the primary agent of change” suggesting that the outcome of the therapy, in this case hypnotherapy, is most successful when the therapist pays attention to the clients own ideas and wisdom. (Kate Kitchen 2005) More specifically, paying attention to the client’s faith, persistence, their support outside of the session including family and friends and work colleagues, community involvement, job, or ability to cope in a crisis situation. (Hubble et al 1999).

An example of a client who might have come for a session or a series of sessions in order to combat their difficulties with anxiety around making presentations at work. Careful metaquestioning of the client prior to the first session and building good rapport, and then further questioning in subsequent sessions would help the therapist to ascertain the client’s views on how they came to have this problem but also their beliefs and understanding of the world in which they exist. It is important to be mindful and respectful of the client’s beliefs and experiences regardless of whether, as the therapist, we believe them to be false as the client has constructed their understanding of their world in such a way that makes sense to them. Extratherapeutic factors in this case could be the fact that the client was bullied at school as a child and ‘lost their voice’ to speak publically, or that they are not listened to in the home environment when they express an opinion, or they might have difficulties in expressing their needs in work due to overbearing colleagues. If the client is female and adheres to a faith or religion which requires females to be quiet and subservient they may have difficulty standing in front of a room full of men and telling them what to do. It is important for the therapist to respect and work carefully with the client with regards to their experience and understanding of their world and to find ways of allowing the client to realise that while their understanding and construct of their world is valid, there may be other options available to them.

It is very important to listen to, learn about and respect a client's extratherapeutic factors as they can greatly affect the success of the outcome of the therapeutic intervention. If, for example a client was presenting with weight issues and regular overeating and they are of the belief that they are ‘unable’ to lose weight because of genetics (one or more close family members may also be overweight), that they will be singled out or rejected for not eating the food that is presented to them on social occasions- food may be a big part of family life and social interactions and they may feel that by not ‘joining in’ that they will be treated with contempt, they may have been overweight as a child and feel that they will never ‘outgrow’ the behaviour or the state of being overweight, maybe at work food features highly, for example having to take clients out for meals, or there being lots of sweet snacks available in an office, if they are absolutely convinced that one session will not deal with their issues then the chances that they will somehow sabotage the treatment to uphold their ingrained understanding of their world are quite high. It would be important then to respect that the client may wish to do the work in stages over several sessions, or address one aspect of the eating patterns at a time. If a client arrived with an inexplicable fear or phobia that couldn’t be easily explained by their own experiences that they can remember, then maybe a course of action would be to do past life regression therapy or current life regression therapy and if this is in conflict with the clients personal, religious or spiritual beliefs, then they may reject the treatment hampering its success and cause conflict within the client and conflict within the client-hypnotist relationship, breeding mistrust and misunderstanding or feeling like their views hadn’t been taken into account.

Correct. I enjoyed your examples and references to sources regarding these factors and the gravitas imposed upon them. Your regard for these factors on public speaking and the social implications of initiating weight control methods are valid and necessary to be aware of. Indeed, they are the reason why ‘it does not work’ for some the first time around and often these factors arise in further sessions. You are also correct in that the weight control client is usually expecting a series of sessions to address their issue, compared to the smoking client who has sometimes been led to believe all will be resolved in just one session. Your linking to past life issues with regard to a therapeutic intervention is a good case in point and can break rapport and cause problems in efficacy further demonstrating your comprehensive appreciation of these factors and impact on outcome.