Beyond Technique: What Makes Therapy Work

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Beyond Technique What Makes Therapy Work?

• Patricia M. Zebrowski, Ph.D.
• University of Iowa

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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?

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Evidence-Based Practice

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

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Evidence-Based Practice

• clinical expertise the ability to use our
  best clinical skills and past experience to
  identify delay or disorder, appropriate
  intervention, and the clients personal values
  and expectations
• The Clinician

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Evidence-Based Practice

• client-values the unique preferences,
  concerns and expectations each client brings to
  the clinical experience
• The Client

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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).

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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

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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

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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.

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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.

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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

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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)

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The Common Factors

• Therapeutic Relationship characteristics of the
  clinician and client (and family) that facilitate
  change and are present regardless of clinicians
  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 clinicians?) belief that treatment will
  help.

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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.

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

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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

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The Dodo Effect in Stuttering Treatment
Research?

• Emerging evidence that between-treatment
  comparisons yield nonsignificant findings
• - Franken, Kielstra-Van Der Schalk
• Boelens (2005)
• AND..

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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)

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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.

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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,
  172-187.
• 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,
  924-943.

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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.

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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.

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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

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Extratherapeutic Change 40
Therapeutic Relationship 30
Expectancy (Placebo) 15
Technique 15
Lambert Bergin (1994) Asay Lambert
(1999) Bernstein Ratner (2005) Franken,
Kielstra-Van der Schalk Boelens (2005)
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• The Common Factors in Stuttering Therapy for
  Children

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TECHNIQUE
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BEHAVIORAL APPROACHES TO STUTTERING TREATMENT

• SPEAK MORE FLUENTLY
• STUTTER MORE FLUENTLY
• NORMAL TALKING PROCESS

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BEHAVIORAL APPROACHES TO STUTTERING TREATMENT

• OPERANT
• (PARA)LINGUISTIC AND ENVIRONMENTAL MANIPULATION
• INTEGRATED APPROACH

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EXTRATHERAPEUTIC
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CHILD STRENGTHS

• Temperament and Personality
• Signature Strengths
• Self-Perception of Control and Competence
• Phonological Abilities

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Temperament

• A largely inherited, multi-faceted construct that
  characterizes a childs general disposition and
  range of moods (Goldsmith, 1987)
• Reactivity excitability of the nervous system
  to behavioral responses or external stimuli

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• Self-regulation the processes that inhibit or
  facilitate reactivity (for example, attention,
  approach-avoidance strategies, etc.)
• Activity lethargic to hyperactive

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• 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.

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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

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• 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.

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• 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.

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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.

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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.

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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

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Signature Strengths - Seligman,
2002

• Are valued in their own rite
• 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

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Signature Strengths - Seligman,
2002

• - Perspective
• - Bravery
• - Perseverance
• - Integrity, honesty
• - Kindness, generosity
• - Loving, and allowing oneself to be loved
• - Citizenship
• - Fairness
• - Leadership

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Signature Strengths - Seligman,
2002

• - Self-control
• - Discretion
• - Humility
• - Appreciation of Beauty
• - Gratitude
• - Optimism
• - Sense of Purpose
• - Forgiveness
• - Humor
• - Enthusiasm

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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.

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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.

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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.

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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

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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).

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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

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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.

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PARENT STRENGTHS

• Congruence
• Signature Strengths
• Able to Shift the Parenting Perspective

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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.

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• 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

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• 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

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Able to Shift the Parenting Perspective

• Fix or force vs ally and advocate
• Refocus comes about through
• - planned communication
• - objective understanding
• - active acceptance

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THERAPEUTIC RELATIONSHIP

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

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• Child and Family Education and Preparation
• Attending to the Childs and Parents Theory of
  Change
• Family Perception of Improvement in Therapy

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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

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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

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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

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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.

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Attending to the Childs and Parents 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)

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Attending to the Childs and Parents 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

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Attending to the Childs and Parents 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 didnt it
  help?
• - Hubble, Duncan Miller, 1999

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Attending to the Childs and Parents 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.

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HOPE or EXPECTANCY
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• Pathways Thinking
• Agency Thinking
• Expectancy Theory

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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

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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).

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Hope or Expectancy

• Expectancy Theory With hope for change comes
  expectancy that change can and will take place.
  An individuals 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
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Hope or Expectancy

• A more positive treatment outcome is likely to
  be predicated on the clients hopefulness, but
  also on the clinicians 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.