1. 1 CHAPTER 6 CHAPTER 6 Facilitating the Therapeutic Process Copyright 2010 Delmar, a part of Cengage Learning. ALL RIGHTS RESERVED. 1

2. 2 On being persistent... Nothing in this world can take the place of persistence. Talent will not; nothing is more common than unsuccessful people with talent. Genius will not; unrewarded genius is almost a proverb. Education will not; the world is full of educated derelicts. Persistence and determination alone are omnipotent. The slogan "press on" has solved and always will solve the problems of the human race....Calvin Coolidge Copyright 2010 Delmar, a part of Cengage Learning. ALL RIGHTS RESERVED. 2

3. 3 Facilitating change Change is difficult (changing more than speech) Change is difficult (changing more than speech) Change is NOT linear or step-wise (more likely to be cyclical) Change is NOT linear or step-wise (more likely to be cyclical) We cannot “push the river.” We cannot “fix” the client and make him do what he is not yet ready to do (Zinker, 1977) We cannot “push the river.” We cannot “fix” the client and make him do what he is not yet ready to do (Zinker, 1977) We cannot pour fluency into a vessel that is not ready of capable of holding itWe cannot pour fluency into a vessel that is not ready of capable of holding it Doing therapy is like creating art and the medium is a human life (Zinker, 1977, p. 37) Doing therapy is like creating art and the medium is a human life (Zinker, 1977, p. 37) Copyright 2010 Delmar, a part of Cengage Learning. ALL RIGHTS RESERVED. 3

4. 4 Facilitating change (continued) A better concept: “priming the canvas” A better concept: “priming the canvas” Cost-benefit ratio (Peck, 1978; Egan, 2007) Cost-benefit ratio (Peck, 1978; Egan, 2007) Loss of old, mistaken belief system/effect on self-esteem (core constructs in PCT) Loss of old, mistaken belief system/effect on self-esteem (core constructs in PCT) Letting GO of highly refined coping responses Letting GO of highly refined coping responses Resulting disequilibrium/disorganization/denial Resulting disequilibrium/disorganization/denial Shadow Side of Change: Idiopathic responses — learned helplessness & a passive lifestyle Shadow Side of Change: Idiopathic responses — learned helplessness & a passive lifestyle Egan (2007) — the price of more effective living may be too high Egan (2007) — the price of more effective living may be too high Copyright 2010 Delmar, a part of Cengage Learning. ALL RIGHTS RESERVED. 4

5. 5 The chances of success? 70% chance of adults gaining substantially improved speech as well as increased speaking confidence (Howie, Tanner, & Andrews, 1981) 70% chance of adults gaining substantially improved speech as well as increased speaking confidence (Howie, Tanner, & Andrews, 1981) Higher than normal scores for some AWS (Hillis & Manning, 1996) Higher than normal scores for some AWS (Hillis & Manning, 1996) Therapy is more associated with specific techniques than microskills (as important as they can be) Therapy is more associated with specific techniques than microskills (as important as they can be) Copyright 2010 Delmar, a part of Cengage Learning. ALL RIGHTS RESERVED. 5

6. 6 Levels of fluency Spontaneous  ideally normal, content > manner (a possible outcome!) Controlled  nearly normal, more vigilance and modification, content = manner, most common Acceptable  requires great vigilance, content < manner Copyright 2010 Delmar, a part of Cengage Learning. ALL RIGHTS RESERVED. 6

7. 7 A stage model of change Prochaska, DiClemente, and Norcross (1992) Change is cyclical through the stages Change is cyclical through the stages (v. step-wise) There are a common set of process that facilitate change (regardless of the treatment approach) There are a common set of process that facilitate change (regardless of the treatment approach) Integration of stages and processes of change Integration of stages and processes of change Copyright 2010 Delmar, a part of Cengage Learning. ALL RIGHTS RESERVED. 7

8. 8 Stages of change Precontemplation: unaware, no intention of change within (~ 6 months) Precontemplation: unaware, no intention of change within (~ 6 months) Contemplation: aware, considering change “soon” Contemplation: aware, considering change “soon” Preparation: ~one month, specific goals & priorities Preparation: ~one month, specific goals & priorities Action: a focus on specific behaviors & criteria, new skills Action: a focus on specific behaviors & criteria, new skills Maintenance: stabilize behavioral and cognitive changes; new and incompatible behaviors in real-life situations. Maintenance: stabilize behavioral and cognitive changes; new and incompatible behaviors in real-life situations. Copyright 2010 Delmar, a part of Cengage Learning. ALL RIGHTS RESERVED. 8

9. 9 Processes of change Increase information; raise consciousness Increase information; raise consciousness Self-reevaluation; change beliefs Self-reevaluation; change beliefs Taking action; belief in ability to change Taking action; belief in ability to change Behavioral change, stimuli, reinforcement, counter- conditioning Behavioral change, stimuli, reinforcement, counter- conditioning Therapeutic support & alliances, historicizing change Therapeutic support & alliances, historicizing change Express and understand emotions (e.g., group Tx) Express and understand emotions (e.g., group Tx) The response & adjustment of others The response & adjustment of others Self-help and support groups, advocacy Self-help and support groups, advocacy Copyright 2010 Delmar, a part of Cengage Learning. ALL RIGHTS RESERVED. 9

10. 10 Potential stage/process mismatches Beginning with modification techniques prior to adequate desensitization Beginning with modification techniques prior to adequate desensitization Using modification behaviors in absence of speaker’s understanding of rationale (temporary success) Using modification behaviors in absence of speaker’s understanding of rationale (temporary success) Focusing on consciousness-raising and self-evaluation (contemplation stage) when the client is ready to take action. Focusing on consciousness-raising and self-evaluation (contemplation stage) when the client is ready to take action. Copyright 2010 Delmar, a part of Cengage Learning. ALL RIGHTS RESERVED. 10

11. 11 Floyd, J., Zebrowski, P., & Flamme, G. A., (2007). Stages of change and stuttering: A preliminary view. Journal of Fluency Disorders, 32, 95-120. Found support for a stages of change model for determining a speaker’s readiness for change with 44 adolescents and adults who stutter Found support for a stages of change model for determining a speaker’s readiness for change with 44 adolescents and adults who stutter Used a modified Stages of Change Questionnaire to confirm the sequence of stages of change for individuals moving through stuttering treatment Used a modified Stages of Change Questionnaire to confirm the sequence of stages of change for individuals moving through stuttering treatment Likely to find greater sensitivity to these changes with a device designed for the unique characteristics of the stuttering experience Likely to find greater sensitivity to these changes with a device designed for the unique characteristics of the stuttering experience Copyright 2010 Delmar, a part of Cengage Learning. ALL RIGHTS RESERVED. 11

12. 12 Goals for change Increasing fluency Increasing fluency Improving communication Improving communication Developing greater autonomy (agency) Developing greater autonomy (agency) Copyright 2010 Delmar, a part of Cengage Learning. ALL RIGHTS RESERVED. 12

13. 13 Agentic Agentic behavior “Agency is thought of as the ability to live life and achieve a voice in a literal as well as a metaphorical sense; or you could think of it as having a lifestyle where the person can act for themselves and speak on their own behalf.” ( Monk, G., Winslade, J., Crocket, K, & Epston, D., 1997) ( Monk, G., Winslade, J., Crocket, K, & Epston, D., 1997) Copyright 2010 Delmar, a part of Cengage Learning. ALL RIGHTS RESERVED. 13

14. 14 Drewery, W., Winslade, J., Monk, G. (2000) Resisting the dominating story: Toward a deeper understanding of narrative therapy. In R. Neimeyer & J. D. Raskin (Eds.), Constructions of Disorder. Washington, D.C.: American Psychological Association. “Health, in our view, has much to do with the capacity for agency and less to do with the absence of disease.” (p. 256) Copyright 2010 Delmar, a part of Cengage Learning. ALL RIGHTS RESERVED. 14

15. 15 The issue of evidenced-based practice (Sacket et al., 2000) Copyright 2010 Delmar, a part of Cengage Learning. ALL RIGHTS RESERVED. 15 “...the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients...“...the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients... “... the integration of best research evidence with clinical experience and patient values.”“... the integration of best research evidence with clinical experience and patient values.”

16. 16 Evidenced-based treatment Smith & Pell (2003), British Medical Journal Parachutes reduce the risk of injury after gravitational challenge, but their effectiveness has not been proved with randomized controlled trials Copyright 2010 Delmar, a part of Cengage Learning. ALL RIGHTS RESERVED. 16

17. 17 Evidence based practice based on a medical model? The gold standard: RCTs Ethical issues & other problems* Withholding treatment from controlsWithholding treatment from controls Learning from previous treatment(s)Learning from previous treatment(s) Placebo effects (4-15%)Placebo effects (4-15%) Compelling but superficial evidenceCompelling but superficial evidence Support for “brands”Support for “brands” * See Ratner, N. (2005). Evidenced-based practice in stuttering: Some questions to consider. J. Fluency Disorders, 30(1), 163-188. Copyright 2010 Delmar, a part of Cengage Learning. ALL RIGHTS RESERVED. 17

18. 18 Other problems Tyrannized by evidence (Sackett et al., 2000) Tyrannized by evidence (Sackett et al., 2000) Using evidenced-based practice as a club Using evidenced-based practice as a club Our real choice is not between treatment protocols that advocates indicate have received the necessary levels of empirical support and what these same authors deem as non- efficacious treatment. This, however, is the only choice that is sometimes offered. (Ratner, 2005) Our real choice is not between treatment protocols that advocates indicate have received the necessary levels of empirical support and what these same authors deem as non- efficacious treatment. This, however, is the only choice that is sometimes offered. (Ratner, 2005) Copyright 2010 Delmar, a part of Cengage Learning. ALL RIGHTS RESERVED. 18

19. 19 Ratner (2005) Currently “without substantial evidence” is not the same as “without substantial value.” Currently “without substantial evidence” is not the same as “without substantial value.” Some efficacious treatments are not acceptable Some efficacious treatments are not acceptable intention-to-treatintention-to-treat noncompliancenoncompliance Copyright 2010 Delmar, a part of Cengage Learning. ALL RIGHTS RESERVED. 19

20. 20 Westen and Morrison (2001). Journal of Counseling and Clinical Psychology, 69, 875- 899 “To infer that one treatment is more efficacious than another because one has been subjected to empirical scrutiny using a particular set of procedures and the other... has not is a logical error.” (p. 878) A need to distinguish the notion of empirically unvalidated from empirically invalidated treatments Copyright 2010 Delmar, a part of Cengage Learning. ALL RIGHTS RESERVED. 20

21. 21 Beyond efficacy data indicating that a treatment works... we need to understand why it works so... we can understand the cause-and-effect relationships that are operating and adjust a protocol for individuals and circumstances, especially when things don’t work Copyright 2010 Delmar, a part of Cengage Learning. ALL RIGHTS RESERVED. 21

22. 22 The medical model implies... Specific treatment ingredients for remediation (development of manuals) Specific treatment ingredients for remediation (development of manuals) Situates the therapist as an extraspective observer of objective medical “facts” Situates the therapist as an extraspective observer of objective medical “facts” And, the DSM-IV (Diagnostic and Statistical Manual of AMA) categories general and nonfunctional (see Raskin & Lewandowski, 2000) And, the DSM-IV (Diagnostic and Statistical Manual of AMA) categories general and nonfunctional (see Raskin & Lewandowski, 2000) Copyright 2010 Delmar, a part of Cengage Learning. ALL RIGHTS RESERVED. 22

23. 23 Other considerations A disease-entity approach that tends to pathologize the person and cast them in a passive role with experts needed to cure them (Kelly, 1955; Monk, 1997). A disease-entity approach that tends to pathologize the person and cast them in a passive role with experts needed to cure them (Kelly, 1955; Monk, 1997). Encourages the use of terms such as: disorder, pathology, symptoms, patient, cure, treatment Encourages the use of terms such as: disorder, pathology, symptoms, patient, cure, treatment... Consider another model?... Consider another model? Copyright 2010 Delmar, a part of Cengage Learning. ALL RIGHTS RESERVED. 23

24. 24 Wampold, B. (2001). The great psychotherapy debate: models, methods and findings. Lawrence Erlbaum: Mahwah, NJ >250 distinct psychotherapetic approaches >250 distinct psychotherapetic approaches >10,000 books; wide variety of problems (depression, anxiety +) >10,000 books; wide variety of problems (depression, anxiety +) Basic goal: to explain the factors that contribute to an over-riding theory (meta-theory) that best accounts for successful treatment outcomes in counseling & ΨTx Basic goal: to explain the factors that contribute to an over-riding theory (meta-theory) that best accounts for successful treatment outcomes in counseling & ΨTx Closely related to fluency therapy Closely related to fluency therapy Copyright 2010 Delmar, a part of Cengage Learning. ALL RIGHTS RESERVED. 24

25. 25 Wampold’s findings There are consistent findings across studies using many different treatment approaches that psychotherapy is remarkably efficacious. (e.g., absolute efficacy—treatment compared to no treatment). There are consistent findings across studies using many different treatment approaches that psychotherapy is remarkably efficacious. (e.g., absolute efficacy—treatment compared to no treatment). Measures of effect size (an index of how much a dependent variable (the outcome of treatment in this case) can be controlled, predicted, or explained by a independent variable (treatment or no treatment in this case) were found to average.80 (a large effect in the social sciences). Measures of effect size (an index of how much a dependent variable (the outcome of treatment in this case) can be controlled, predicted, or explained by a independent variable (treatment or no treatment in this case) were found to average.80 (a large effect in the social sciences). Copyright 2010 Delmar, a part of Cengage Learning. ALL RIGHTS RESERVED. 25

26. 26 Wampold’s findings (continued) Effect sizes for different treatments reached a maximum of.20, a difference that is inconsequential theoretically or clinically. Effect sizes for different treatments reached a maximum of.20, a difference that is inconsequential theoretically or clinically. Furthermore, measures of relative efficacy— comparisons of different treatments—appear to be inflated by the differences in the effectiveness of the clinicians delivering the therapy. Furthermore, measures of relative efficacy— comparisons of different treatments—appear to be inflated by the differences in the effectiveness of the clinicians delivering the therapy. Copyright 2010 Delmar, a part of Cengage Learning. ALL RIGHTS RESERVED. 26

27. 27 Wampold’s findings (continued) The medical model implies that there are specific therapeutic ingredients necessary for the remediation of a disorder; thus manuals specifying clinician adherence to the ingredients. The medical model implies that there are specific therapeutic ingredients necessary for the remediation of a disorder; thus manuals specifying clinician adherence to the ingredients. Consistent findings of uniform efficacy across treatments provide indirect evidence that specific ingredients associated with treatment approaches are not responsible for Tx benefits. Consistent findings of uniform efficacy across treatments provide indirect evidence that specific ingredients associated with treatment approaches are not responsible for Tx benefits. Copyright 2010 Delmar, a part of Cengage Learning. ALL RIGHTS RESERVED. 27

28. 28 Wampold’s findings (continued) Little support for the medical model for explaining treatment outcomes. Specific ingredients account for only 1% of the variance in outcomes. Little support for the medical model for explaining treatment outcomes. Specific ingredients account for only 1% of the variance in outcomes. Placebo effects (containing some but not all factors common to many treatments) account for 4% of the variability. Placebo effects (containing some but not all factors common to many treatments) account for 4% of the variability. Copyright 2010 Delmar, a part of Cengage Learning. ALL RIGHTS RESERVED. 28

29. 29 In fact... Relative efficacy studies have shown that the use of manuals does not increase the benefits of psychotherapy. Relative efficacy studies have shown that the use of manuals does not increase the benefits of psychotherapy. In fact, there are indications that strict adherence to a treatment protocol may have detrimental effects as it tends to suppresses the effect of clinician competence. In fact, there are indications that strict adherence to a treatment protocol may have detrimental effects as it tends to suppresses the effect of clinician competence. Results also suggest that training therapists to adhere to a manual can result in deteriorating interpersonal relations between the therapist and the client. Results also suggest that training therapists to adhere to a manual can result in deteriorating interpersonal relations between the therapist and the client. Copyright 2010 Delmar, a part of Cengage Learning. ALL RIGHTS RESERVED. 29

30. 30 Wampold’s findings (continued) There are many factors that are common across treatment approaches that do much better in accounting for variance in treatment outcome. Among these are: There are many factors that are common across treatment approaches that do much better in accounting for variance in treatment outcome. Among these are: working alliance between the client and the clinician accounting for 5%working alliance between the client and the clinician accounting for 5% clinician allegiance to the treatment protocol (whatever the treatment) accounting for up to 10%.clinician allegiance to the treatment protocol (whatever the treatment) accounting for up to 10%. quality of the therapist accounts for up to 22%quality of the therapist accounts for up to 22% * This is similar to similar to previous findings by... Copyright 2010 Delmar, a part of Cengage Learning. ALL RIGHTS RESERVED. 30

31. 31 Miller, S. D., Duncan, B. L., & Hubble, M.A. (1997) Escape from Babel: Toward a Unifying Language for Psychotherapy Practice. W. W. Norton & Company, New York & London A summary of the findings: Extratherapeutic events, accounting for some 40% of positive outcome Extratherapeutic events, accounting for some 40% of positive outcome Client-therapist alliance: 30% Client-therapist alliance: 30% Placebo effects: 15% Placebo effects: 15% Method or technique: 15% Method or technique: 15% Extra Tx 40% Relation 30% Placebo 15% Method 15% Copyright 2010 Delmar, a part of Cengage Learning. ALL RIGHTS RESERVED. 31...based on 40 years of empirical and clinical research that facilitate positive change in clients regardless of the therapeutic approach.

32. 32 Wampold & colleagues concluded... A Common Factors (or Contextual) Model does a better job of explaining therapeutic change than the Medical Model. See also: Rosenzweig, S. (1936), Smith and Glass (1977) See also: Rosenzweig, S. (1936), Smith and Glass (1977) It may be that support for a treatment protocol containing a set of factors provides support for other protocols also containing these factors. Copyright 2010 Delmar, a part of Cengage Learning. ALL RIGHTS RESERVED. 32

33. 33 The common factors model The Common Factors Model of psychotherapy stipulates that there is a common set of factors across treatments that result in a successful treatment outcome. In fact, results are emerging for... Copyright 2010 Delmar, a part of Cengage Learning. ALL RIGHTS RESERVED. 33

34. 34... the equivalency of both empirically- validated and informed treatments in fluency disorders Hancock, K., & Craig, A. (1998). Predictors of stuttering relapse one year following treatment for children aged 9 to 14 years. Journal of Fluency Disorders, 23, 31–48. Hancock, K., & Craig, A. (1998). Predictors of stuttering relapse one year following treatment for children aged 9 to 14 years. Journal of Fluency Disorders, 23, 31–48. Huinck, W. J. & Peters, H. F. M. (2004). Effect of speech therapy on stuttering: Evaluating three therapy programs. Paper presented to the IALP Congress, Brisbane. Huinck, W. J. & Peters, H. F. M. (2004). Effect of speech therapy on stuttering: Evaluating three therapy programs. Paper presented to the IALP Congress, Brisbane. Franken, M. C., Van der Schalk, C. J., & Boelens, H. (2005). Experimental treatment of early stuttering: A preliminary study, Journal of Fluency Disorders, 30, 189-199. Franken, M. C., Van der Schalk, C. J., & Boelens, H. (2005). Experimental treatment of early stuttering: A preliminary study, Journal of Fluency Disorders, 30, 189-199. Herder, C. Howard, C., Nye, C., & Vanyckeghem, M. (2006). Effectiveness of behavioral stuttering treatment: A systematic review and meta-analysis. Contemporary Issues in Communication Science and Disorders, 33, 61-73. Herder, C. Howard, C., Nye, C., & Vanyckeghem, M. (2006). Effectiveness of behavioral stuttering treatment: A systematic review and meta-analysis. Contemporary Issues in Communication Science and Disorders, 33, 61-73. Copyright 2010 Delmar, a part of Cengage Learning. ALL RIGHTS RESERVED. 34

35. 35 Effect of speech therapy on stuttering Comparing three therapy programs Wendy J. Huinck Herman F.M. Peters University Medical Center Nijmegen, Dept. of Otorhinolaryngology, the Netherlands 2004 IALP Congress 29 August to 2 September 2004, Brisbane, Australia Copyright 2010 Delmar, a part of Cengage Learning. ALL RIGHTS RESERVED. 35

36. 36 Three treatment programs (adults) 1. Fluency shaping group therapy CSP (The Comprehensive Stuttering Program 2. Stuttering modifying group therapy DM (Doetinchemse Methode) 3. Individualized Stuttering therapy VSN (Vereniging Stottercentra Nederland) pre therapy Data Collection Data Collection: a. Pre therapy b. Post therapy c. Follow up 1 (one year after therapy) d. Follow up 2 (two years after therapy) Copyright 2010 Delmar, a part of Cengage Learning. ALL RIGHTS RESERVED. 36

37. 37 Results Fluency Dramatic improved fluency but regression with CSP Only subtle differences between programs on the long term Improved speech satisfaction in all three programs Speech quality No loss of speech quality in terms of articulation and voice Substantial improved speech quality in stuttering modification program (DM) Emotions and cognitions Substantial improved self-reports in all three programs (Less anxiety, improved fluency, improved self-concepts) Copyright 2010 Delmar, a part of Cengage Learning. ALL RIGHTS RESERVED. 37

38. 38 Herder et al. (2006) (adults) From 1798 articles, 12 met inclusion criteria From 1798 articles, 12 met inclusion criteria (random assignment + experimental & control group) (random assignment + experimental & control group) Typical participant: 18-year-old male, one hr Tx for 12.5 weeks; Tx- behavioral, time-out, desensitization, DCM Typical participant: 18-year-old male, one hr Tx for 12.5 weeks; Tx- behavioral, time-out, desensitization, DCM Absolute efficacy of.91 Absolute efficacy of.91 Relative efficacy of.21 Relative efficacy of.21 Conclusion: Conclusion: “... the critical element(s) for successful intervention might not lie with the intervention itself (p. 70) but in the common element(s) found in many treatment approaches.” Copyright 2010 Delmar, a part of Cengage Learning. ALL RIGHTS RESERVED. 38

39. 39 In addition, the common factors model is... Less dogmatic than the medical model concerning specific ingredients.Less dogmatic than the medical model concerning specific ingredients. Allows eclecticism as long as there is a rationale that underlies treatment and that rationale is cogent, coherent, and psychologically based (Empirically informed or validated).Allows eclecticism as long as there is a rationale that underlies treatment and that rationale is cogent, coherent, and psychologically based (Empirically informed or validated). Emphasizes the healing context and the meaning attributed to it by the participants (both therapist and client).Emphasizes the healing context and the meaning attributed to it by the participants (both therapist and client). Copyright 2010 Delmar, a part of Cengage Learning. ALL RIGHTS RESERVED. 39

40. 40 Ahn & Wampold (2001) meta-analysis of component studies in counseling and psychotherapy. Journal of Counseling Psychology, 48, 251-257. Success may be more likely to occur if both the client and the clinician share a similar view of the process and the objectives Success may be more likely to occur if both the client and the clinician share a similar view of the process and the objectives In fact, Ahn & Wampold suggest that people seeking help would be well advised to search for particular clinicians rather than particular treatments In fact, Ahn & Wampold suggest that people seeking help would be well advised to search for particular clinicians rather than particular treatments Copyright 2010 Delmar, a part of Cengage Learning. ALL RIGHTS RESERVED. 40

41. 41 Options for the clinician Be a student of your field—don’t rely on a treatment package Be a student of your field—don’t rely on a treatment package Employ empirically informed approaches Employ empirically informed approaches Understand WHY something works Understand WHY something works Experiment with principles that fit the person Experiment with principles that fit the person Work the program, calibrate to and follow the client Work the program, calibrate to and follow the client Model experimentation & alternative explanations Model experimentation & alternative explanations Be curious, cautious of dogma and the “rhetoric of pseudoscience” Be curious, cautious of dogma and the “rhetoric of pseudoscience” Copyright 2010 Delmar, a part of Cengage Learning. ALL RIGHTS RESERVED. 41