Beyond Technique in Stuttering Therapy: A Search for the “Common Factors” Patricia M. Zebrowski, Ph.D. University of Iowa USA

The Great Therapy Debate: Different Fields, Same Questions. What therapy approach “works best?” What is the evidence? Are there different kinds of evidence? If so, do they receive equal weight in treatment planning? How does evidence translate into clinical practice?

Evidence-Based Practice Evidence-based practice is the integration of the best research evidence with clinical expertise and client values. 1.‘best research’ = ‘outcomes research’ or clinically relevant research into the accuracy,precision, and efficacy of diagnostic tests and treatments The Technique

Evidence-Based Practice 2.‘clinical expertise’ = the ability to use our best clinical skills and past experience to identify delay or disorder, appropriate intervention, and the client’s personal values and expectations The Clinician

Evidence-Based Practice 3.‘client-values’ = the unique preferences, concerns and expectations each client brings to the clinical experience The Client

What Can We Learn from Psychotherapy Research? Numerous studies have compared the effectiveness of different therapeutic approaches for depression, anxiety, schizophrenia, etc. Many of these investigations consisted of meta-analyses of the efficacy of various types of therapy (e.g. Wampold, Mondin, Moody, Stich, Benson & Ahn, 1997).

What Can We Learn from Psychotherapy Research? With rare exception, research has uncovered little significant difference among different psychotherapeutic approaches. This observation has been described as “the dodo effect” (e.g. Tallman & Bohart, 2004). “Everybody has won and all must have prizes” - Lewis Carroll

Explaining the “Dodo Effect” Different therapy approaches use dissimilar strategies or processes to achieve the same outcome Research methods may not be sensitive enough to detect differences in therapeutic effectiveness among approaches OR differences are so subtle that they cannot be observed using conventional between-group designs

Explaining the “Dodo Effect” Studies of treatment efficacy do not provide objective descriptions or operational definitions of therapy protocol (i.e., client-centered). Studies of treatment efficacy do not provide the quantitative information to allow for inclusion in meta-analysis There are common factors throughout all therapies that facilitate change or progress.

Explaining the “Dodo Effect” It is the similarities, rather than the differences, between approaches that account for the observation that all psychotherapeutic approaches are, in general, effective.

Explaining the “Dodo Effect” These similarities can be collapsed into four factors or elements that are common to all forms of psychotherapy: Technique Extratherapeutic Change Therapeutic Relationship Hope or Expectancy

The Common Factors Techniques – factors or ‘strategies’ unique to different therapy approaches (e.g. “easy onset”, “voluntary stuttering”) Extratherapeutic Change – characteristics of the client and his/her environment (e.g. temperament, social support)

The Common Factors Therapeutic Relationship – characteristics of the clinician and client (and family) that facilitate change and are present regardless of clinician’s therapy orientation (i.e. ‘technique’). Components include shared goals, agreement on methods, means and tasks for treatment, and an emotional bond (Bordin, 1979). Expectancy – Hope; sometimes thought of as “placebo”. Improvement that results from client (and clinician’s?) belief that treatment will help.

Explaining the “Dodo Effect” Further…. Lambert (1992) and Asay and Lambert (1999) reviewed the extant literature and concluded that these factors (separate and combined) account for most of the change observed in therapy.

Therapeutic Relationship 30% Extratherapeutic Change 40% Technique 15% Expectancy (Placebo) 15% Lambert & Bergin (1994) Asay & Lambert (1999) Bernstein Ratner (2005) Franken, Kielstra-Van der Schalk & Boelens (2005)

The “Dodo” Effect in Speech and Language Treatment Research? Robey, R. (1998). A meta-analysis of clinical outcomes in the treatment of aphasia. JSLHR, 41, Law, J., Garrett, Z., Nye, C. (2004). The efficacy of treatment for children with developmental speech and language delay/disorder: A meta-analysis. JSLHR, 47,

The “Dodo” Effect in Speech and Language Treatment Research? Gillam, R., Loeb, D., Friel-Patti, S., Hoffman, L., Brandel, J., Champlin, C., Thibodeau, L., Widen, J., Bohmah, T., Clarke, W. (2005). Randomized comparison of language intervention programs. ASHA.

The “Dodo” Effect in Speech and Language Treatment Research? Treatment better than no treatment On average, treatment is effective Different effect sizes most likely due to client characteristics, “age” or severity of problem, clinician skill-level, differences in social validity for individual clients, and so forth.

The “Dodo” Effect in Speech and Language Treatment Research? Further research to support the conclusion that in general, “therapy works” would waste resources. Future work should aim toward testing focused hypotheses (i.e., client characteristics + clinician skill + treatment approach). Robey, 1998

The “Dodo” Effect in Stuttering Treatment Research? Treatment approaches with published evidence of efficacy and effectiveness are: - response-contingent time-out - parent administered operant - GILCU and ELU

- prolonged/smooth speech - parent-child interaction therapy - SSMP Outcome measures vary

The “Dodo” Effect in Stuttering Treatment Research? Emerging evidence that between- treatment comparisons yield nonsignificant findings when dependent variable is similar. - Franken, Kielstra-Van Der Schalk & Boelens (2005)

The “Dodo” Effect in Stuttering Treatment Research? Herder, Howard, Nye & Vanryckeghem (2006). Effectiveness of behavioral stuttering treatment: A systematic review and meta- analysis. Contemporary Issues in Communication Science and Disorders, 33,

“Results support the claim that intervention for stuttering results in an overall positive effect. Additionally, the data show that no one treatment approach for stuttering demonstrates significantly greater effects over another treatment approach.” Herder, Howard, Nye & Vanryckeghem (2006). Effectiveness of behavioral stuttering treatment: A systematic review and meta-analysis. Contemporary Issues in Communication Sciences and Disorders, 3,

Therapeutic Relationship 30% Extratherapeutic Change 40% Technique 15% Expectancy (Placebo) 15% Lambert & Bergin (1994) Asay & Lambert (1999) Bernstein Ratner (2005) Franken, Kielstra-Van der Schalk & Boelens (2005)

The Common Factors in Stuttering Therapy for School-Age Children

TECHNIQUE

EXTRATHERAPEUTIC CHANGE

CHILD STRENGTHS Resilience “Signature Strengths” Perceived Competence and Control Phonological Abilities

Temperament A largely inherited, multi-faceted construct that characterizes a child’s general disposition and range of moods (Goldsmith, 1987) Temperament mediates the influence of the environment on the child Reactivity – excitability of the nervous system to behavioral responses or external stimuli

Emotionality – emotional response to new or novel stimuli Self-regulation – the processes that inhibit or facilitate reactivity (for example, attention, approach- avoidance strategies, etc.)

Resilience Children who are successful at regulating excitability and emotional reactivity exhibit resilience. Children are described as resilient when their temperament and related adaptive skills (or personality traits) facilitate the ability to “bounce back”, or take negative experiences (e.g. stuttering) in stride.

Resilience Further, these children may exhibit a more dominant (i.e. less timid), extraverted and sociable personality, and are inclined to readily and positively approach social situations, including therapy. May display a relatively high degree of attentional focusing and risk-taking in therapy and in social (communication) situations. Temporal substrate of rhythmicity may benefit from practice effects in therapy. All may contribute to progress in therapy OR unassisted recovery.

“Signature Strengths” - Seligman, 2002 An important construct in “Positive Psychology” ( Are seen across cultures Are psychological traits seen across different situations over time

“Signature Strengths” - Seligman, 2002 Can be acquired and measured Contribute to adaptive coping - Curiosity, interest in the world - Love of learning - Judgment, critical thinking, open- mindedness - Ingenuity, practical intelligence - Emotional intelligence

“Signature Strengths” - Seligman, Perspective - Bravery - Perseverance - Integrity, honesty - Kindness, generosity - Loving, and allowing oneself to be loved - Citizenship - Fairness - Leadership

“ Signature Strengths” - Seligman, Self-control - Discretion - Humility - Appreciation of Beauty - Gratitude - Optimism - Sense of Purpose - Forgiveness - Humor - Enthusiasm

Self-Perception of Control and Competence Research in youth sport participation has shown that internal locus of control = higher self-perception of competence, and vice versa (i.e. external locus of control). Internal locus of control serves as a protective factor in children who exhibit high levels of trait anxiety or abuse/neglect.

Self-Perception of Control and Competence Internal locus of control characterizes children who are motivated to engage in a particular activity or learning task, and maintain a high level of interest across time (e.g. therapy). Equivocal evidence that internal locus of control facilitates short-term gains in stuttering therapy.

Phonological Abilities Evidence suggests that children who stutter are more likely to exhibit (co-existing) phonological delay or disorder when compared to their nonstuttering peers (Louko, Edwards and Conture, 1990; Paden and Yairi, 1996; Paden, Yairi and Ambrose, 1999; Paden, 2005). AND…

Phonological Abilities Comparisons of children who recover from, and persist in, stuttering show that the persistent group are more likely to achieve poorer scores across a number of tests of phonological proficiency (Paden and Yairi, 1996; Paden, Yairi and Ambrose, 1999; Paden, 2005).

Phonological Abilities Some children who stutter may exhibit developmental asynchronies (Watkins, Yairi and Ambrose, 1999; Watkins, 2005), perhaps contributing to a lower threshold for perturbation or disruption. FURTHER…

Phonological Abilities Children who stutter who have age- appropriate phonology and speech articulation are more likely to experience a positive therapy outcome that is attained relatively quickly. Young children close to onset with no co-occurring phonological problems are more likely to experience unassisted recovery.

PARENT STRENGTHS Congruence “Signature Strengths” Able to Shift the Parenting Perspective

Congruence Congruence helps parents to respond to a situation with both intellect (rational intelligence) and emotion. An idealized situation that is difficult to attain. As people, we all need to work continually to attain congruence; as clinicians, we want to help our clients to attain it.

Different styles of internal organization - high or low in intellect - high or low in affect High intellect: focus on facts; deny or repress emotions High affect: difficulty in processing information

We want to help a parent who is intellectually oriented to gain access to and express feelings We want to help a parent who is affect oriented to express feelings so he/she can begin to process information

Able to Shift the Parenting Perspective “Fix” or “force” vs “ally and advocate” Refocus comes about through: - planned communication - objective understanding - active acceptance

THERAPEUTIC RELATIONSHIP Shared goals, agreement on methods, means and tasks for treatment, and an emotional bond (Bordin, 1979).

Child and Family Education and Preparation Attending to the Child’s and Parent’s “Theory of Change”

Child and Family Education and Preparation Coleman, D. & Kaplan, M. (1990). Effects of pretherapy video preparation on child therapy outcomes. Professional Psychology: Research and Practice, 21(3),

Child and Family Education and Preparation Limited understanding of clinical process OR mismatch between child and family expectations and realities encountered leads to poor therapeutic relationship AND Puts child and family at greater risk for dropping out of therapy

Child and Family Education and Preparation Child and family will respond positively to treatment when engaged in an exploration of various topics, including: - nature of stuttering - contemporary theories of etiology - why children come for therapy - the general structure of therapy - some specifics of behavior change

Child and Family Education and Preparation - what will be taught and why - the importance of active participation - self-expression - trust and confidentiality - child, parent and clinician roles and responsibilities - examples of positive outcomes and how they were achieved

Attending to the Child’s and Parent’s “Theory of Change” “Within the client is a theory of change waiting for discovery, a frame-work for intervention to be unfolded and accommodated for a successful outcome” (Hubble, Duncan & Miller, 1999)

Attending to the Child’s and Parent’s “Theory of Change” What ideas do you have about what needs to happen for improvement to occur? Often people have a hunch about what is causing a problem, and also how they can resolve it. Do you have a theory of how change is going to happen here? In what ways do you see me and this process helpful in attaining your goals? - Hubble, Duncan & Miller, 1999

Attending to the Child’s and Parent’s “Theory of Change” How does change usually happen in your life? What do you do to initiate change? What have you tried to help with stuttering so far? Did it help? How did it help? Why didn’t it help? - Hubble, Duncan & Miller, 1999

Attending to the Child’s and Parent’s “Theory of Change” Each client and family presents the clinician with a new theory to learn and a new, client-directed intervention to suggest. Research in psychotherapy has shown that what the client and family want from treatment, how these goals are accomplished, and their perception of improvement may be the most important factors in therapy.

HOPE or EXPECTANCY

Pathways Thinking Agency Thinking “Expectancy Theory”

Hope or Expectancy Pathways thinking – developing one or two ways to accomplish change Agency thinking – the ability to begin and persist in doing what is necessary to change. Inability to experience either pathways or agency thinking causes stress and difficulty in coping

Hope or Expectancy The positive emotion that stems from the ability to successfully engage in both pathways and agency thinking is the essence of hope. Hope is not a purely emotional phenomenon; it is an emotional response that is rooted in cognition. - Barnum, Snyder, Rapoff, Mani & Thompson, 1998).

Hope or Expectancy “Expectancy Theory” – With hope for change comes expectancy that change can and will take place. An individual’s belief that a certain treatment will yield a certain effect either triggers or correlates to that effect. Expectancy Theory has long been used to explain the placebo effect in medicine. Hope or Expectancy

A more positive treatment outcome is likely to be predicated on the client’s hopefulness, but also on the clinician’s hope and expectation that the client has the ability to change, and that they will be able to help the client bring about such change.