The National The National Stuttering AssociationStuttering Association

Scottsdale, AZ - 2009Scottsdale, AZ - 2009

Walt Manning, Ph.D.Walt Manning, Ph.D.

School of Audiology & School of Audiology & Speech-Language Speech-Language

PathologyPathology

The University of The University of MemphisMemphis

wmanning@memphis.eduwmanning@memphis.edu

Common factors for successful therapy

Clinician factors & principles of change

Wampold, B. (2001). Wampold, B. (2001). The great The great psychotherapy debate: models, methods psychotherapy debate: models, methods

and findingsand findings. Lawrence Erlbaum: . Lawrence Erlbaum: Mahwah, NJMahwah, NJ

• Basic goal: to explain the Basic goal: to explain the factors that contribute to an factors that contribute to an over-riding theory (meta-over-riding theory (meta-theory) that best accounts for theory) that best accounts for successful treatment successful treatment outcomes in counseling & outcomes in counseling & psychotherapy.psychotherapy.

• Closely related to fluency Closely related to fluency treatmenttreatment

Wampold’s FindingsWampold’s Findings

• Measures of Measures of absolute efficacyabsolute efficacy (treatment vs no (treatment vs no treatment): treatment):

effect size of effect size of .80.80 a large effect in the social sciencesa large effect in the social sciences Consistent findings across studies of Consistent findings across studies of

many different treatment approaches many different treatment approaches that psychotherapy is remarkably that psychotherapy is remarkably efficacious. efficacious.

Wampold’s FindingsWampold’s Findings

• Measures of Measures of relative efficacyrelative efficacy (comparisons of (comparisons of different treatments):different treatments):

Effect size of Effect size of .20.20 inconsequential effect theoretically or inconsequential effect theoretically or

clinically clinically

• Differences between treatments appear to be Differences between treatments appear to be inflated by the effectiveness of the clinicians inflated by the effectiveness of the clinicians delivering the therapy. delivering the therapy.

Wampold’s FindingsWampold’s Findings

• Found little support for the Found little support for the medical modelmedical model for explaining treatment outcomesfor explaining treatment outcomes

• specific ingredients account for only specific ingredients account for only 1%1% of of the variance in outcomes the variance in outcomes

• Placebo effects account for Placebo effects account for 4%4% of the of the variability variability

Furthermore. . .Furthermore. . .

• The use of The use of manualsmanuals does not increase the does not increase the benefits of psychotherapy. benefits of psychotherapy.

• Strict adherence to a treatment protocol may Strict adherence to a treatment protocol may have have detrimental effectsdetrimental effects as it tends to as it tends to suppresses the effect of suppresses the effect of clinician clinician competencecompetence..

• Adherence to a manual can result in a Adherence to a manual can result in a deteriorating therapeutic relationshipdeteriorating therapeutic relationship..

So how to explain success?So how to explain success?

• Factors that are Factors that are commoncommon across treatment across treatment approaches do much better in accounting for approaches do much better in accounting for variance in treatment outcome. variance in treatment outcome.

• The The working allianceworking alliance between the client and the between the client and the clinician accounted for up to clinician accounted for up to 5%5%

• Clinician allegianceClinician allegiance to the treatment protocol to the treatment protocol (whatever the treatment) accounted for up to(whatever the treatment) accounted for up to 10%10%

• The The quality of the therapistquality of the therapist accounted for up to accounted for up to 22%22%

Previous authors & researchers Previous authors & researchers had predicted this outcome:had predicted this outcome:

Rosenzweig, S. (1936)Rosenzweig, S. (1936)

Smith & Glass (1977) Smith & Glass (1977)

Miller, S. D., Duncan, B. L., & Hubble, M.A. (1997)Miller, S. D., Duncan, B. L., & Hubble, M.A. (1997)

In addition the common In addition the common factors model . . .factors model . . .

• is less dogmatic than the is less dogmatic than the medical modelmedical model concerning specific ingredients. concerning specific ingredients.

• allows eclecticism as long as there is a allows eclecticism as long as there is a rationale that underlies treatment and that rationale that underlies treatment and that rationale is Empirically informed or validatedrationale is Empirically informed or validated

• emphasizes the healing context and the emphasizes the healing context and the meaning attributed to it by the participants meaning attributed to it by the participants (both therapist and client). (both therapist and client).

From:From:Ahn & Wampold (2001) meta-analysis of component Ahn & Wampold (2001) meta-analysis of component studies in counseling and psychotherapy. studies in counseling and psychotherapy. Journal of Journal of

Counseling PsychologyCounseling Psychology, 48, 251-257., 48, 251-257.

• success may be more likely to occur if both success may be more likely to occur if both the client and the clinician share a similar the client and the clinician share a similar view of the process and the objectivesview of the process and the objectives

• people seeking help would be well advised to people seeking help would be well advised to search for particular search for particular cliniciansclinicians rather than rather than particular treatmentsparticular treatments

Similar findings now occurring for Similar findings now occurring for fluency disordersfluency disorders

• Hancock, K., & Craig, A. (1998). Predictors of stuttering Hancock, K., & Craig, A. (1998). Predictors of stuttering relapse one year following treatment for children aged 9 relapse one year following treatment for children aged 9 to 14 years. to 14 years. Journal of Fluency DisordersJournal of Fluency Disorders, 23, 31–48., 23, 31–48.

• Huinck, W. J. & Peters, H. F. M. (2004). Effect of speech Huinck, W. J. & Peters, H. F. M. (2004). Effect of speech therapy on stuttering: Evaluating three therapy therapy on stuttering: Evaluating three therapy programs. Paper presented to the IALP Congress, programs. Paper presented to the IALP Congress, Brisbane. Brisbane.

• Franken, M. C., Van der Schalk, C. J., & Boelens, H. Franken, M. C., Van der Schalk, C. J., & Boelens, H. (2005). (2005). Experimental treatment of early stuttering: A Experimental treatment of early stuttering: A preliminary study, preliminary study, Journal of Fluency DisordersJournal of Fluency Disorders, 30, 189-, 30, 189-199.199.

• Herder, C. Howard, C., Nye, C., & Vanyckeghem, M. Herder, C. Howard, C., Nye, C., & Vanyckeghem, M. (2006). Effectiveness of behavioral stuttering treatment: (2006). Effectiveness of behavioral stuttering treatment: A systematic review and meta-analysis. Contemporary A systematic review and meta-analysis. Contemporary Issues in Communication Science and Disorders, 33, 61-Issues in Communication Science and Disorders, 33, 61-73.73.

The essential structure of an The essential structure of an effectiveeffective therapeutic interactiontherapeutic interaction

An effective therapeutic interaction is characterized by the An effective therapeutic interaction is characterized by the development of a therapeutic alliance between the client and clinician development of a therapeutic alliance between the client and clinician from which the client feels empowered and is able to autonomously from which the client feels empowered and is able to autonomously engage in agentic behavior leading to cognitive change. As a result, engage in agentic behavior leading to cognitive change. As a result, the client becomes a more effective communicator with greater the client becomes a more effective communicator with greater fluency. Implicit in such therapeutic interaction are characteristics of fluency. Implicit in such therapeutic interaction are characteristics of clinicians that facilitate the development of the therapeutic alliance. clinicians that facilitate the development of the therapeutic alliance. These include being professional, passionate, committed, and These include being professional, passionate, committed, and confident, and understanding the nature and depth of the stuttering confident, and understanding the nature and depth of the stuttering experience, including its treatment. Such clinicians believe in the experience, including its treatment. Such clinicians believe in the therapeutic process and in the client’s ability to accomplish therapeutic process and in the client’s ability to accomplish therapeutic change. They are client driven and employ clinical therapeutic change. They are client driven and employ clinical decision-making that accounts for the client's needs, capabilities, and decision-making that accounts for the client's needs, capabilities, and personal goals. They actively listen to their clients with a patient and personal goals. They actively listen to their clients with a patient and caring demeanor, building feelings of confidence, acceptance, caring demeanor, building feelings of confidence, acceptance, understanding, trust, and a desire on the part of the client to take an understanding, trust, and a desire on the part of the client to take an active role in the treatment process.active role in the treatment process.

Plexico, Manning & DiLollo, ASHA 2009Plexico, Manning & DiLollo, ASHA 2009

The essential structure of an The essential structure of an ineffectiveineffective therapeutic interactiontherapeutic interaction

An ineffective therapeutic interaction is characterized by a failure An ineffective therapeutic interaction is characterized by a failure to develop a therapeutic alliance between client and clinician, to develop a therapeutic alliance between client and clinician, leaving clients feeling misunderstood, inadequate, shameful, leaving clients feeling misunderstood, inadequate, shameful, discouraged, and without hope, and generating little motivation discouraged, and without hope, and generating little motivation and desire to attend therapy. This often occurs due to a clinician’s and desire to attend therapy. This often occurs due to a clinician’s dogmatic adherence to a particular therapeutic protocol and dogmatic adherence to a particular therapeutic protocol and associated techniques, poor knowledge about the nature and associated techniques, poor knowledge about the nature and depth of the stuttering experience, a lack of interest in the depth of the stuttering experience, a lack of interest in the nuances of therapeutic change, poor listening skills, and nuances of therapeutic change, poor listening skills, and inattentiveness to the client’s capabilities and goals. Such inattentiveness to the client’s capabilities and goals. Such interactions often result in further negative emotions of interactions often result in further negative emotions of frustration, anger, embarrassment, and guilt.frustration, anger, embarrassment, and guilt.

  

Plexico, Manning & DiLollo, ASHA 2009Plexico, Manning & DiLollo, ASHA 2009

Three Goals for ChangeThree Goals for Change**

Increase fluencyIncrease fluencyImprove communication Improve communication

Develop greater autonomyDevelop greater autonomy ((agencyagency))

**Therapeutic & Self-Directed changeTherapeutic & Self-Directed change

Agentic Agentic Behavior

““Agency is thought of as the ability to live life Agency is thought of as the ability to live life andand

achieve a voice in a literal as well as a achieve a voice in a literal as well as a metaphoricalmetaphorical

sense; or you could think of it as having a sense; or you could think of it as having a lifestylelifestyle

where the person can act for themselves and where the person can act for themselves and speakspeak

on their own behalf.” on their own behalf.”

(Monk, G., Winslade, J., Crocket, K, & Epston, D., (Monk, G., Winslade, J., Crocket, K, & Epston, D., 1997) 1997)

““Health, in our view, has much to do with , in our view, has much to do with the capacity for agency and less to do the capacity for agency and less to do

with the absence of disease.” with the absence of disease.”

Drewery, W., Winslade, J., Monk, G., p. 256

4 Principles of Therapeutic Change4 Principles of Therapeutic Change

Move Move towardtoward rather than away from the rather than away from the problemproblem

Assume the Assume the responsibilityresponsibility for taking action for taking action

RestructureRestructure the cognitive view of the self the cognitive view of the self andand the problem the problem

Recruit the Recruit the supportsupport of others of others