Extra-therapeutic factors affecting the efficacy of therapy

It's common for us to be apprehensive about attending for any appointments or procedures where there is no guaranteed outcome of success, and there's every possibility of relapse despite having left the session with high motivation and the necessary resources to succeed.

Clinicians of all kinds have have debates of who is responsible for the client's changework. Whilst debating whether it's the therapists role, or the client's responsibility,  what is often ignored are other factors beyond the therapy room which the therapist or client are unable to control.

 The therapeutic relationship is a partnership – a dynamic 'both/and' rather than 'either/or'. Our main focus here is to take responsibility for what we can whilst acknowledging the extra-therapeutic factors which surround therapy. 

According to Miller, Duncan and Hubble (1997), in their book Escape from Babel: Toward a Unifying Language for Psychotherapy Practice, extra-therapeutic factors are actually largely responsible for the success or failure of therapy. According to Lambert (1992) extra-therapeutic factors account for 40% of therapeutic outcome, the therapeutic relationship accounts for 30%, therapeutic technique 15%, and expectancy and placebo 15%. Even such cherished notions as the importance of the length of a therapist's professional training, or the style of therapy employed, are, it seems, relatively unimportant compared to these factors.

According to Howard, Kopta, Krause and Orlinsky (1986) research has estimated that 15% of clients show measurable change prior to their first appointment. Weiner-Davis, de Shazer and Gingerich (1987) reported 66% in a study of 30 clients. The latter study was replicated by Lawson (1994) who reported 60% over 82 clients. Clients who experience pre-treatment change are four times more likely to complete their treatment in psychotherapy (Beyerbach, Morejon, Palenzuela and Rodriguez-Aris, 1996).

Where change is of a client's making, it is important they are able to take credit for this. Research shows that those who take credit for their own successes will maintain their gains. Where people are given a placebo substance, those who attribute success to their own efforts are more likely to maintain success, while those who attribute success to the placebo substance are less likely to maintain their gains (Frank, 1976; Liberman, 1978).

Miller, Duncan and Hubble (op. cit.) provide another interesting example of the influence of extra-therapeutic factors. A man was attending therapy, without success. He and his partner had not spoken to one another about anything other than business matters for two years after an enormous argument. They slept in separate rooms. Family came to visit and they lost track of time. It was too late for family to drive home or book a hotel room so the couple had to sleep together to free up a bedroom for them to stay the night. They talked about things other than business and even made love that night. They both turned up to the next therapy session to say things had moved on swiftly. A few sessions later therapy was complete.

In another example they cite a client was, as she put it, 'desperately neurotic'. She had heard about Milton Erickson's great achievements as a therapist and wanted to see him. However, she couldn't bring herself to talk to him about her problems face to face. So she asked him if he would allow her to drive up to his house and park in the driveway and just imagine he was in the car talking about the best way to solve the issue. He agreed and she solved her problem after a couple of visits without his direct input.

Here are some some broad extra-therapeutic factors:

Client history
Client psychology and biology
Client identity
Social & environmental factors
Fortuitous events
Support structures 

Many of these factors mentioned in the lists above also need to be thought about along a time axis, in terms of the past, present and future.

Most of the extra-therapeutic factors are quite straightforward and obvious in their impact. Support structures, however, are often taken-for-granted as unproblematically useful in the talking therapies. Let's therefore offer a critique.

Having family, friends, colleagues, a partner, a manager, a parent, or a mentor supporting the client can bring many benefits. It can help them to stay focused and engaged with therapy and change. Support can mean that therapy is not an isolated island visited once a week, but rather, an ongoing effort, as the supporter can help a client through difficult patches between sessions, and help them to value and attend therapy and recognise changes they may not have noticed by themselves. And a supporter provides the client with someone to celebrate and share their successes with.

On the other hand, support can be a real disadvantage. Support can be withdrawn, for example, when a friendship ends, when the supporter can no longer cope or has troubles of their own that need prioritising, or when they withdraw support out of spite. This leaves your client with a sudden demand for finding another supporter or going it alone. Support can also be dramatically lost when a supporter dies. As well, support can encourage dependency either because the client, the supporter, or both, benefit from this.

Sometimes supporters manipulate. There may be tertiary gain involved, i.e., the supporter benefits from a continuation of the problem. Perhaps they enjoy having a 'needy' friend to talk to and providing support and advice cements the bond between them and makes them feel wanted and important. Some supporters will remind the client of their investments ('look at what I've done for you'). Or they will place too much pressure on the client for changes, usually doing all the things a therapist would not, such as advising and cajoling.

Supporters sometimes undo all the good work of the client and therapist, through cynicism, disbelief in the modality or changes made, perhaps attributing change to luck and undermining the client's sense of control. Some of these things can be offset by looking for the best people for the job of supporter and by building a network of multiple supporters to obtain diverse benefits and spread risk. That said, even a network can have its problems, such as bringing about contradictory advice and confusion.

Edited excerpt taken from Bartle, K. & Peace, P. (2009) The Advanced Hypnotherapist. ISBN: 978-0-9564916-0-2 ebook

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References:

Beyerbach, M., Morejon, A.R., Palenzuela, D.L. and Rodriguez-Aris, J.L. (1996). 'Research on the process of solution-focused therapy' in S.D. Miller, M.A. Hubble and B.L. Duncan (eds.) Handbook of Solution-focused Brief Therapy. San Francisco: Jossey–Bass.

Frank, J.D. (1976) 'Psychotherapy and the sense of mastery' in R.L. Spitzer and D.F. Klein (eds.) Evaluation of Psychotherapies: Behavioural Therapies, Drug Therapies and Their Interaction. Baltimore, MD: Johns Hopkins University Press.

Howard, K.I., Kopte, S.M., Krause, M.S. and Orlinsky, D.E. (1986) 'The dose-effect relationship in psychotherapy'. American Psychologist, 41(2): 159–164.

Liberman, B.L. (1978) 'The maintenance and persistence of change: Long-term follow-up investigations of psychotherapy' in J.D. Frank, R. Hoehn-Sarix, S.D. Imber, B.L. Liberman and A.R. Stone (eds.) Effective Ingredients of Effective Psychotherapy. New York: Brunner/Mazel.

Miller, S.D., Duncan, B.L. and Hubble, M.A. (1997) Escape from Babel: Toward a Unifying Language for Psychotherapy Practice. New York: W. W. Norton & Co.