Why Stuttering Therapy
Works: The “Common Factors”
Patricia M. Zebrowski, Ph.D.
University of Iowa
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
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
Evidence-Based Practice
3. „client-values‟ = the unique
preferences, concerns and
expectations each client brings to the
clinical experience
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?
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”
Finally…..
It is likely that there are common factors
throughout all therapies that facilitate
change or progress.
Explaining the “Dodo Effect”
It is also likely that there are common
factors throughout all therapies that
facilitate change or progress, AND……
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.
Extratherapeutic
Therapeutic Change
Relationship 40%
30%
Expectancy
(Placebo)
15%
Technique
15%
Lambert & Bergin (1994)
Asay & Lambert (1999)
Bernstein Ratner (2005)
Franken, Kielstra-Van der Schalk & Boelens (2005)
The “Dodo” Effect in Stuttering
Treatment Research?
• Limited data available on efficacy of
stuttering therapy for either children or
adults.
• Studies have shown that in general,
treatment is better than no treatment.
• Primary dependent variable is % stuttered
words or syllables.
The “Dodo” Effect in Stuttering
Treatment Research?
• Treatment approaches with the most
evidence of efficacy or effectiveness
are:
- response-contingent time-out
- parent administered operant
- GILCU and ELU
- prolonged/smooth speech
The “Dodo” Effect in Stuttering
Treatment Research?
• Emerging evidence that between-
treatment comparisons yield
nonsignificant findings
- Franken, Kielstra-Van Der Schalk
& Boelens (2005)
AND…..
The “Dodo” Effect in Stuttering
Treatment Research?
Recent meta-analysis of the results from 12
studies of behavioral stuttering treatment
revealed that:
- 6/12 yielded a significant
effect size (treatment/no
treatment; 0.91)
- 6/12 yielded a nonsignificant effect
size (comparison of two treatments;
0.21)
The “Dodo” Effect in Stuttering
Treatment Research?
“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 & Vanryckehgem (2006).
Effectiveness of behavioral stuttering
treatment: A systematic review and meta-
analysis. Contemporary Issues in
Communication Science and Disorders, 33,
61-73.
Extratherapeutic
Therapeutic Change
Relationship 40%
30%
Expectancy
(Placebo)
15%
Technique
15%
Lambert & Bergin (1994)
Asay & Lambert (1999)
Bernstein Ratner (2005)
Franken, Kielstra-Van der Schalk & Boelens (2005)
The Common Factors in Stuttering
Therapy for Children
TECHNIQUE
BEHAVIORAL APPROACHES TO
STUTTERING TREATMENT
• SPEAK MORE FLUENTLY
• STUTTER MORE FLUENTLY
• NORMAL TALKING PROCESS
BEHAVIORAL APPROACHES TO
STUTTERING TREATMENT
• OPERANT
• (PARA)LINGUISTIC AND
ENVIRONMENTAL MANIPULATION
• INTEGRATED APPROACH
SPEAK MORE FLUENTLY
(aka “Fluency Shaping” or “Smooth Speech” via
Fluency-Enhancing Strategies)
• Slow rate
• Prolonged vowels
• Slow and smooth speech initiation
• Phrasing and pausing
• Light articulatory contact
• Connecting across word boundaries
• Goals of Therapy: Spontaneous and
controlled fluency
ENTIRE SPEECH PATTERN IS
CHANGED
STUTTER MORE FLUENTLY
(aka “Stuttering Modification”)
• Identify and modify moments or instances
of stuttering
• Reducing fear of stuttering and speaking
• Reducing or eliminating avoidance
behaviors
• Counseling
• Goals of Therapy: Spontaneous fluency,
controlled fluency, and acceptable
stuttering (aka “easy” stuttering)
MOMENTS OR INSTANCES OF
STUTTERING ARE CHANGED
„NORMAL TALKING‟ PROCESS
• Introduced by Williams (1957; 1979)
• Instead of focusing on reducing or replacing
undesirable behavior, emphasis is placed
on increasing desirable behavior.
• Attention is directed away from the
perception of what is happening to child ,
toward those things (s)he is doing to both
facilitate and interfere with talking.
„NORMAL TALKING‟ PROCESS
Emphasis placed on behavioral awareness of
five parameters that contribute to „forward
moving speech.‟
- tensing
- movement
- airflow
- voicing
- timing
OPERANT
• ELU (Costello; 1975; 1984)
• Lidcombe (Onslow and colleagues; e.g.
1990;1994)
• GILCU (Ryan, e.g. 1974; 1995)
Published Outcomes Available
(PARA)LINGUISTIC AND
ENVIRONMENTAL MANIPULATION
• GILCU (Ryan)
• ELU (Costello)
• Clinician and Parent Modeling of slow rate,
light articulatory contact, increased turn-
switching pause time, appropriate turn-
taking behaviors, etc. (Conture, 2001;
Starkweather and Gottwald,1991; Zebrowski
and Kelly, 2002).
LINGUISTIC AND ENVIRONMENTAL
MANIPULATION (cont‟d)
• Clinician and Parent use short, simple
utterances and avoid “over-talking.”
• Structured therapy sessions designed to
facilitate spontaneous fluency and turn-
taking
• Parent counseling
Published Outcomes Available
INTEGRATED APPROACH
• Exploration of Talking and Stuttering: Start
from “Normal Talking” Model (behavioral
awareness and desensitization)
• Changing Talking: Fluency enhancing
strategies across entirety of speech
• Changing Stuttering: Modification of
moments or instances of stuttering
INTEGRATED APPROACH
• “Mental Training” to enhance motor
learning (permanent improvement in
skill). Think: coaching.
• Relaxation
• Addressing thoughts and feelings
through cognitive restructuring and
listening.
EXTRATHERAPEUTIC
CHILD STRENGTHS
• Temperament and Personality
• “Signature Strengths”
• Self-Perception of Control and
Competence
• Phonological Abilities
Temperament
• A largely inherited, multi-faceted construct
that characterizes a child‟s general
disposition and range of moods
(Goldsmith, 1987)
• Reactivity – excitability of the nervous
system to behavioral responses or
external stimuli
• Self-regulation – the processes that
inhibit or facilitate reactivity (for
example, attention, approach-
avoidance strategies, etc.)
• Activity – lethargic to hyperactive
• Emotionality – emotional response to new or
novel stimuli
• Sociability – comfort in being alone as
opposed to being with other
Temperament mediates the influence of the
environment on the child.
The “Behaviorally Inhibited”
(BI) Child
• Described by Kagan (1984; 1994) as
one type of normal temperamental
profile
• Relatively timid, sensitive to
environment and own behaviors, higher
levels of reactivity and lower thresholds
for excitability than other children
• Based on results from administration of
the Temperament Characteristic Scale
(TCS) and the Parent Perception Scale,
Oyler (1996a, 1996b) and Oyler and
Ramig (1995) determined that young
children who stutter were significantly
more behaviorally inhibited and less
likely to take risks than children who do
not stutter.
• Further, Anderson, Pellowski, Conture &
Kelly (2003) used similar measures and
observed that children who stutter are
less adaptable, less rhythmic in
physiological functioning, and less
distractible than their nonstuttering
peers.
Resilience
• Children who are successful at regulating f
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”
• (www.authentichappiness.org)
• Are seen across cultures
• Are psychological traits seen across
different situations over time
“Signature Strengths”
- Seligman, 2002
• Are valued in their own rite
• Can be acquired and can be 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, 2002
- Perspective
- Bravery
- Perseverance
- Integrity, honesty
- Kindness, generosity
- Loving, and allowing oneself to be
loved
- Citizenship
- Fairness
- Leadership
“Signature Strengths”
- Seligman, 2002
- 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.
Self-Perception of Control and
Competence
• Finally, evidence suggests that children
who stutter tend to have a negative
attitude about communication, that
increases with age (DeNil and Brutten,
1996).
• A negative attitude about communication
are significantly correlated with increased
stuttering, negative emotion, and fears
about speaking.
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”
• Family Perception of Improvement in
Therapy
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
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),
199-203.
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
Hope or treatment will yield a
belief that a certain Expectancy
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.