The Meaning Response as Applied to Stuttering Therapy

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The Meaning Response as Applied to Stuttering
Therapy

• John A. Tetnowski, Ph.D., CCC-SLP, BRS/M-FD
• Kathleen Scaler Scott, M.S., CCC-SLP, BRS/M-FD
• Jack S. Damico, Ph.D., CCC-SLP, BRS/M-FD
• University of Louisiana at Lafayette

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The history behind this project

• A little bit of magic fairy dust?

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The impact of meaning upon stuttering therapy
success

• What is truly meant by the placebo effect?
• What is the meaning response?
• What studies support the meaning response?
• How does knowing this help us to plan treatment?
• How does knowing this help us to plan future
  research?

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The placebo effectreinterpreted (Moerman, 2002)

• Originally understood as changes produced by an
  inert therapeutic condition, i.e. a placebo
• Conflict in definition because placebos are inert
• If something is inert, it causes no change or
  effect
• But yet placebos are said to cause a change or
  effect

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The meaning response(Moerman, 2002)

• Psychological and physiological effects of
  meaning in the treatment of illness (Moerman, p.
  14)
• Positive effects include most of the things known
  as the placebo effect negative effects include
  most of the things known as the nocebo effect
  (both are meaning based)
• It also includes things that are not
  traditionally part of the placebo effect (active
  vs. inert meds)

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Studies Supporting the Meaning Response

• Meaning response results from interaction with a
  perceived healing context
• Physical changes (Lanza, Goff, Scowcroft,
  Jennings, Greski-Rose, 1994)
• Brand name has an effect upon pain reduction of
  aspirin and placebo (Braithwaite Cooper, 1981)
• What doctors know makes a difference (Gracely,
  Dubner, Deeter, Wolskee, 1985)
• How strongly doctors believe in the effectiveness
  of treatments makes a difference (Uhlenhuth et.
  al, 1966)
• Skeptics can heal 30 to 40 of their patients
  with inert medication, while enthusiasts can heal
  70 to 90 (Benson McCallie, 1979)

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Studies Supporting the Meaning Response

• Form of treatment has an impact upon healing
• Color pill and its intended purpose (Blackwell,
  Bloomfield Buncher, 1972)
• Number of pills (Blackwell, Bloomfield Buncher,
  1972)
• Pill vs. Shot in U.S. (de Craen, Tijssen, de
  Gans, Kleijnen, 2000)in Europe less of an
  effect
• Surgery works even if not real (Thomsen, Bretlau,
  Tos, Johnson, 1981)
• Placebo has an effect upon pain reduction only if
  patient knows its happening (Benedetti, 1996)
• Response varies with culture (Lock, 1986)

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Current Trends in the field of Stuttering

• Client-centered focus (Rogers, 1946)
• Clinician involvement in self-help groups
  (Reeves, 2006 Yaruss et al., 2002)
• Clients as consumers (Reeves, 2006 Yaruss
  Quesal, 2004a Yaruss Quesal, 2004b)
• Consumer role on advisory boards and
  credentialing organizations
• Call for research partnership between clinicians,
  researchers, consumers (Yaruss Quesal, 2004a
  Yaruss Reeves, 2002 Yaruss et al., 2001 )

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Current Trends in the field of Stuttering

• Consumer needs havent changed, but our response
  to them has
• Changes in what researchers are willing to study
• Health insurance payments for alternative
  approaches (Cleary-Guida, Okvat, Oz, Ting,
  2001)
• Client perspective studies on recovery (Finn,
  1996 Finn, Howard Kubala, 2005), treatment
  (Plexico, Manning DiLollo, 2005), role of
  support groups (Trichon, 2006 Yaruss et al.,
  2002)

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Current Trends in the field of Stuttering

• Multifactorial theory of stuttering and
  implications for treatment (Smith, 1999 Smith
  Kelly, 1997)
• What works for a client
• One therapy?
• Combinations of therapy?
• Depends upon what each means for a client

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To understand whats meaningful to a client

• Constructivism Meaning shaped by the interaction
  of language and experience in clients life
  (Vygotsky 1934, 1986)
• Meaning is socially constructed (Berger
  Luckman, 1966)
• Lock (1986)
• de Craen et al. (2000)

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To understand whats meaningful to a client

• Whats meaningful for a CLIENT and for an SLP in
  terms of therapy is initially shaped by
• Culture (home environment, education system)
• Background
• Experiences
• And is further shaped by
• Experiences (Kamhi, 1994)
• Interactions with others (Yaruss Quesal, 2004a)
• An SLP example

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So what does this say about therapy?

• Skeptics and how we present approach really
  matters (Lidcombe Speecheasy examples)
• Form of treatment may make a difference
• High technology vs. low technology
• Ongoing vs. intensive
• Individual vs. group

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So what does this say about therapy?

• Who administers the treatment may make a
  differencebut it all depends upon the consumers
  perspective of each scenario
• Specialist vs. non-specialist
• Masters vs. Ph.D.
• New clinician vs. experienced clinician
• Person who stutters or not
• A client example

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Clinician-Client Congruence (Manning, 1999) Am
I aware of what my belief system is?

• Maybe rather than asking which treatment
  strategy is best, we should be asking the
  infinitely more complex question of why a
  particular strategy or technique might be best
  for a certain clinician, for a particular client,
  at a specific time (Manning, p. 128)
• Increased progress when patient and doctor are in
  agreement (Starfield et. al, 1981)
• Congruence leads to comfort
• Comfort leads to confidence

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What about the true believer?

• Role of clinician confidence and the meaning
  response
• How strongly doctors believe in the effectiveness
  of treatments makes a difference (Uhlenhuth et
  al., 1966)
• Skeptics can heal 30 to 40 of their patients
  with inert medication, while enthusiasts can heal
  70 to 90 (Benson McCallie, 1979)
• Kamhi (1994)
• Being a true believer allows you not to slip
  into the tentacles of relativism, but needs to
  be flexible to realize that there may be more
  than one way to teach something (p. 197)

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Within confidence lies our socially constructed
view of effectiveness

• What does effectiveness mean to you as a
  clinician?
• Elimination of stuttering?
• Communicating without avoidance?
• If you witness success through an approach that
  is not congruent with yours, what are you left
  feeling skeptical about?

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Within confidence lies our socially constructed
view of effectiveness

• If our approach is not congruent with our
  definition of success, it becomes difficult to
  exude the level of confidence necessary to evoke
  the meaning response in our clients.
• If you use and are confident in a singular
  approach, this may not be an issue.
• If you are focused on client-centered therapy,
  you must have confidence in the clients ability
  to drive the therapy and the approaches to a
  certain extent. (A real life example)

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An approach to therapy vs. a therapy approach
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Strupp (1986)Four Elements to Effective
Psychotherapeutic Process

• Guided by a theory
• Therapist creates and maintains interpersonal
  context
• Therapist seeks to understand meaning behind
  clients behavior
• Therapist attempts to reformulate meaning in a
  way for client to use it productively

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What does this look like?

• Narrative therapy (Neimeyer, 1995)
• Cognitive restructuring
• Fluency Shaping approach
• Stuttering Modification approach
• The Lidcombe Program (Onslow Packman, 1999)

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So what does this say about therapy?

• Perhaps any approach will work if it is grounded
  in theory
• But we must consider the meaning of it for the
  client, because this is the bottom line
• If fluency shaping means to a client, I should
  avoid stuttering at all costs, avoidances may
  remain
• If stuttering modification means to a client, I
  can never have complete fluency, motivation may
  decrease (ex. with adolescents)

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So what does this say about therapy?

• Your confidence in the method and your expression
  of this confidence can have a significant impact
  upon progress (this may be a case for specialist
  vs. non-specialist)
• If you must project confidence and believe in
  some theory, then you need congruence between
  therapist and approach

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So what does this say about therapy?

• The meaning response is triggered by what the
  client valuesthis should help guide your choice
  of approach (Seligman, 1995)
• Brand names, such as specialists, may make a
  difference just from perception
• Putting someone on a waiting list and giving them
  suggestions is in fact some type of meaning-based
  treatmentthis has significant implication for
  spontaneous recovery rates of preschoolers

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So what does this say about therapy?

• Form of treatment may make a difference
• Length of Therapy
• Number of sessions per week
• Meaning of form will tend to vary by culture

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So what does this say about therapy?

• Grounding in a theory is important, but what
  theory is less important
• Experience may be less important if other
  components are therehowever, experience may
  bring things like grounding in theory

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So what do I do Monday morning with my clients?

• Know your paradigm and be flexible within it
• Ground your approach in theorynot trial and
  error
• Use an approach you can justify and have
  confidence in
• Project your confidence in the approach
• Be there with your clientslisten and understand
  their needs

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So what do I do Monday morning with my clients?

• If you are a skeptic about the approach the
  client wants, you may want to consider sending
  them to someone elsebut on the other handif you
  are flexible within your paradigm, this can work
  if you can
• Be flexible and move your ego out of the way

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So how do we establish meaning?

• Have client journal things like
• What do you think the reasoning is behind what
  youre working on in therapy?
• What lesson/message do you take away from the
  activities were working on?
• What does fluency mean to you?
• What does stuttering mean to you?
• What are your perceptions of your fluency skills?

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How about research?

• We need to look at the meaning effect closely
  and examine its impact upon stuttering therapy
  outcomes
• Compare the psychotherapy research with that of
  stuttering therapy, following the methods of
  Strupp (1986)
• Ethnographic interviews with successful
  therapists from all paradigms to find out the
  basic principles they follow in therapy

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References

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Questions?scalerscott1_at_earthlink.nettetnowski_at_l
ouisiana.edujsdamico_at_louisiana.edu