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.
