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

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CHAPTERCHAPTER 66

Facilitating the Therapeutic ProcessFacilitating the Therapeutic Process

Copyright 2010 Delmar, a part of Cengage Learning. ALL RIGHTS RESERVED. 1

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On being persistent . . .On being persistent . . .

Nothing in this world can take the place of persistence. Nothing in this world can take the place of persistence. Talent will not; nothing is more common than unsuccessful Talent will not; nothing is more common than unsuccessful

people with talent.people with talent.Genius will not; unrewarded genius is almost a proverb. Genius will not; unrewarded genius is almost a proverb. Education will not; the world is full of educated derelicts. Education will not; the world is full of educated derelicts. Persistence and determination alone are omnipotent. Persistence and determination alone are omnipotent. The slogan "press on" has solved and always will solve the The slogan "press on" has solved and always will solve the

problems of the human raceproblems of the human race..

. . .Calvin Coolidge. . .Calvin Coolidge


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Facilitating changeFacilitating change

• Change is difficult (changing more than speech) Change is difficult (changing more than speech)

• Change is Change is NOTNOT linear or step-wise (more likely to be linear or step-wise (more likely to be cyclical)cyclical)

• We cannot “push the river.” We cannot “fix” the We cannot “push the river.” We cannot “fix” the client and make him do what he is not yet ready to client and make him do what he is not yet ready to do (Zinker, 1977)do (Zinker, 1977)

• We cannot pour fluency into a vessel that is not We cannot pour fluency into a vessel that is not ready of capable of holding itready of capable of holding it

• Doing therapy is like creating art and the medium is Doing therapy is like creating art and the medium is a human life (Zinker, 1977, p. 37) a human life (Zinker, 1977, p. 37)


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Facilitating changeFacilitating change(continued)(continued)

• A better concept: “priming the canvas” A better concept: “priming the canvas” • Cost-benefit ratio Cost-benefit ratio (Peck, 1978; Egan, 2007)(Peck, 1978; Egan, 2007)

• Loss of old, mistaken belief system/effect on self-esteem Loss of old, mistaken belief system/effect on self-esteem (core constructs in PCT)(core constructs in PCT)

• Letting GO of highly refined coping responsesLetting GO of highly refined coping responses

• Resulting disequilibrium/disorganization/denialResulting disequilibrium/disorganization/denial

• Shadow Side of Change: Idiopathic responsesShadow Side of Change: Idiopathic responses——learned learned helplessness & a passive lifestylehelplessness & a passive lifestyle

• Egan (2007)Egan (2007)——the price of more effective living may be the price of more effective living may be too hightoo high


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The chances of success?The chances of success?

• 70% chance of adults gaining substantially improved 70% chance of adults gaining substantially improved speech as well as increased speaking confidence speech as well as increased speaking confidence (Howie, Tanner, & Andrews, 1981) (Howie, Tanner, & Andrews, 1981)

• Higher than normal scores for some AWS (Hillis & Higher than normal scores for some AWS (Hillis & Manning, 1996)Manning, 1996)

• Therapy is more associated with specific techniques Therapy is more associated with specific techniques than microskills (as important as they can be) than microskills (as important as they can be)


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Levels of fluencyLevels of fluency

SpontaneousSpontaneous ideally normal, content > manner ideally normal, content > manner (a possible outcome!)(a possible outcome!)

ControlledControlled nearly normal, more vigilance and nearly normal, more vigilance and

modification, content = manner, most commonmodification, content = manner, most common

AcceptableAcceptable requires great vigilance, content < requires great vigilance, content < manner manner


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A stage model of changeA stage model of change

Prochaska, DiClemente, and Norcross (1992) Prochaska, DiClemente, and Norcross (1992)

• Change is Change is cyclicalcyclical through the stages through the stages

(v. step-wise)(v. step-wise)

• There are a There are a commoncommon set of process that facilitate set of process that facilitate change (regardless of the treatment approach)change (regardless of the treatment approach)

• IntegrationIntegration of stages and processes of change of stages and processes of change


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Stages of changeStages of change

• Precontemplation:Precontemplation: unaware, no intention of unaware, no intention of change within (~ 6 months)change within (~ 6 months)

• Contemplation:Contemplation: aware, considering change “soon”aware, considering change “soon”

• Preparation:Preparation: ~one month, specific goals & ~one month, specific goals & prioritiespriorities

• Action:Action: a focus on specific behaviors & criteria, a focus on specific behaviors & criteria, new skillsnew skills

• Maintenance:Maintenance: stabilize stabilize behavioralbehavioral and and cognitivecognitive changes; new and incompatible behaviors changes; new and incompatible behaviors

in in real-life situationsreal-life situations..


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Processes of change Processes of change

• Increase information; raise consciousnessIncrease information; raise consciousness• Self-reevaluation; change beliefsSelf-reevaluation; change beliefs• Taking action; belief in ability to changeTaking action; belief in ability to change• Behavioral change, stimuli, reinforcement, counter-Behavioral change, stimuli, reinforcement, counter-

conditioningconditioning• Therapeutic support & alliances, historicizing changeTherapeutic support & alliances, historicizing change• Express and understand emotions (e.g., group Tx)Express and understand emotions (e.g., group Tx)• The response & adjustment of othersThe response & adjustment of others• Self-help and support groups, advocacySelf-help and support groups, advocacy


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Potential stage/process mismatchesPotential stage/process mismatches

• Beginning with modification techniques prior to adequate Beginning with modification techniques prior to adequate desensitizationdesensitization

• Using modification behaviors in absence of speaker’s Using modification behaviors in absence of speaker’s understanding of rationale (temporary success)understanding of rationale (temporary success)

• Focusing on consciousness-raising and self-evaluation Focusing on consciousness-raising and self-evaluation (contemplation stage) when the client is ready to take (contemplation stage) when the client is ready to take action. action.


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Floyd, J., Zebrowski, P., & Flamme, G. A., (2007). Floyd, J., Zebrowski, P., & Flamme, G. A., (2007). Stages of change and stuttering: A preliminary view. Stages of change and stuttering: A preliminary view.

Journal of Fluency DisordersJournal of Fluency Disorders, 32, 95-120., 32, 95-120.

• Found support for a Found support for a stages of change modelstages of change model for for determining a speaker’s readiness for change with determining a speaker’s readiness for change with 44 adolescents and adults who stutter 44 adolescents and adults who stutter

• Used a modified Stages of Change Questionnaire Used a modified Stages of Change Questionnaire to confirm the sequence of stages of change for to confirm the sequence of stages of change for individuals moving through stuttering treatmentindividuals moving through stuttering treatment

• Likely to find greater sensitivity to these changes Likely to find greater sensitivity to these changes with a device designed for the unique with a device designed for the unique characteristics of the stuttering experience characteristics of the stuttering experience


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Goals for changeGoals for change

• Increasing fluencyIncreasing fluency• Improving communication Improving communication • Developing greater autonomy (agency)Developing greater autonomy (agency)


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Agentic Agentic behavior

““Agency is thought of as the ability to live life andAgency is thought of as the ability to live life andachieve a voice in a literal as well as a metaphoricalachieve a voice in a literal as well as a metaphoricalsense; or you could think of it as having a lifestylesense; or you could think of it as having a lifestylewhere the person can act for themselves and speakwhere the person can act for themselves and speakon their own behalf.” on their own behalf.”

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


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Drewery, W., Winslade, J., Monk, G. (2000) Resisting the Drewery, W., Winslade, J., Monk, G. (2000) Resisting the dominating story: Toward a deeper understanding of narrative dominating story: Toward a deeper understanding of narrative therapy. In R. Neimeyer & J. D. Raskin (Eds.), therapy. In R. Neimeyer & J. D. Raskin (Eds.), Constructions of Constructions of

DisorderDisorder. Washington, D.C.: American Psychological Association.. Washington, D.C.: American Psychological Association.

““Health, in our view, has much to do with the capacity Health, in our view, has much to do with the capacity for agency and less to do with the absence of for agency and less to do with the absence of disease.” (p. 256)disease.” (p. 256)


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The issue of evidenced-basedThe issue of evidenced-basedpractice practice

(Sacket et al., 2000)(Sacket et al., 2000)


•““. . .the conscientious, explicit, and judicious use of . . .the conscientious, explicit, and judicious use of current best current best evidenceevidence in making decisions about the in making decisions about the care of individual patients . . . care of individual patients . . .

•““. . . the integration of best . . . the integration of best research evidenceresearch evidence with with clinical experienceclinical experience and and patient valuespatient values.”.”

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Evidenced-based treatmentEvidenced-based treatmentSmith & Pell (2003), Smith & Pell (2003), British Medical JournalBritish Medical Journal

Parachutes reduce the risk of injury after Parachutes reduce the risk of injury after gravitational challenge, but their effectiveness gravitational challenge, but their effectiveness has not been proved with randomized controlled has not been proved with randomized controlled trials trials


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Evidence based practice based Evidence based practice based on a medical model?on a medical model?

The gold standard: RCTsThe gold standard: RCTs

Ethical issues & other problems*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:See Ratner, N. (2005). Evidenced-based practice in stuttering:

Some questions to consider. Some questions to consider. J. Fluency DisordersJ. Fluency Disorders, 30(1), 163-188., 30(1), 163-188.


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Other problemsOther 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 Our real choice is not between treatment

protocols that advocates indicate have received protocols that advocates indicate have received the necessary levels of empirical support and the necessary levels of empirical support and what these same authors deem as non-what these same authors deem as non-efficacious treatment. This, however, is the efficacious treatment. This, however, is the only choice that is sometimes offered. (Ratner, only choice that is sometimes offered. (Ratner, 2005)2005)


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Ratner (2005)Ratner (2005)

• Currently “without substantial evidence” is not Currently “without substantial evidence” is not the same as “without substantial value.”the same as “without substantial value.”

• Some efficacious treatments are not acceptableSome efficacious treatments are not acceptable• intention-to-treatintention-to-treat• noncompliancenoncompliance


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Westen and Morrison (2001). Westen and Morrison (2001). Journal of Counseling Journal of Counseling and Clinical Psychologyand Clinical Psychology, 69, 875-899, 69, 875-899

““To infer that one treatment is more efficacious than To infer that one treatment is more efficacious than another because one has been subjected to another because one has been subjected to empirical scrutiny using a particular set of empirical scrutiny using a particular set of procedures and the other. . . has not is a logical procedures and the other. . . has not is a logical error.” (p. 878)error.” (p. 878)

A need to distinguish the notion of A need to distinguish the notion of empirically empirically unvalidatedunvalidated from from empirically invalidated empirically invalidated treatments treatments


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Beyond efficacy data indicating Beyond efficacy data indicating that a treatment works . . .that a treatment works . . .

we need to understand we need to understand whywhy it works so . . . it works so . . .

we can we can understandunderstand the the cause-and-effect relationships cause-and-effect relationships that are operating and that are operating and adjustadjust a protocol for individuals and a protocol for individuals and

circumstances, especially when things don’t workcircumstances, especially when things don’t work


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The medical model implies . . .The medical model implies . . .

• Specific treatment ingredients for remediation Specific treatment ingredients for remediation (development of manuals)(development of manuals)

• Situates the therapist as an extraspective observer Situates the therapist as an extraspective observer of objective medical “facts”of objective medical “facts”

• And, the DSM-IV (Diagnostic and Statistical Manual And, the DSM-IV (Diagnostic and Statistical Manual of AMA) categories general and nonfunctional of AMA) categories general and nonfunctional (see (see Raskin & Lewandowski, 2000) Raskin & Lewandowski, 2000)


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Other considerationsOther considerations

• A disease-entity approach that tends to pathologize A disease-entity approach that tends to pathologize the person and cast them in a passive role with the person and cast them in a passive role with experts needed to cure them (Kelly, 1955; Monk, experts needed to cure them (Kelly, 1955; Monk, 1997).1997).

• Encourages the use of terms such as: Encourages the use of terms such as: disorder, disorder, pathology, symptoms, patient, cure, treatmentpathology, symptoms, patient, cure, treatment

• . . . Consider another model?. . . Consider another model?


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

Lawrence Erlbaum: Mahwah, NJLawrence Erlbaum: Mahwah, NJ

• >250 distinct psychotherapetic approaches >250 distinct psychotherapetic approaches

• >10,000 books; wide variety of problems (depression, >10,000 books; wide variety of problems (depression, anxiety +)anxiety +)

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

• Closely related to fluency therapyClosely related to fluency therapy


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Wampold’s findingsWampold’s findings

• There are consistent findings across studies using There are consistent findings across studies using many different treatment approaches that many different treatment approaches that psychotherapy is remarkably efficacious. (e.g., psychotherapy is remarkably efficacious. (e.g., absoluteabsolute efficacyefficacy——treatment compared to no treatment). treatment compared to no treatment).

• Measures of effect size (an index of how much a Measures of effect size (an index of how much a dependent variable (the dependent variable (the outcomeoutcome of treatment in this of treatment in this case) can be controlled, predicted, or explained by a case) can be controlled, predicted, or explained by a independent variable (treatment or no treatment in this independent variable (treatment or no treatment in this case) were found to average case) were found to average .80.80 (a large effect in the (a large effect in the social sciences).social sciences).


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Wampold’s findings (continued)Wampold’s findings (continued)

• Effect sizes for Effect sizes for differentdifferent treatments reached a treatments reached a maximum of maximum of .20.20, a difference that is inconsequential , a difference that is inconsequential theoretically or clinically. theoretically or clinically.

• Furthermore, measures of Furthermore, measures of relative efficacyrelative efficacy——comparisons of different treatmentscomparisons of different treatments——appear to be appear to be inflated by the differences in the effectiveness of the inflated by the differences in the effectiveness of the clinicians delivering the therapy. clinicians delivering the therapy.


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• TheThe medical modelmedical model implies that there are implies that there are specific specific therapeutic ingredientstherapeutic ingredients necessary for the necessary for the remediation of a disorder; thus manuals specifying remediation of a disorder; thus manuals specifying clinician adherence to the ingredients.clinician adherence to the ingredients.

• Consistent findings of uniform efficacy across Consistent findings of uniform efficacy across treatments provide indirect evidence that specific treatments provide indirect evidence that specific ingredients associated with treatment approaches ingredients associated with treatment approaches are not responsible for Tx benefits. are not responsible for Tx benefits.


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• Little support for the Little support for the medical modelmedical model for explaining for explaining treatment outcomes. Specific ingredients account treatment outcomes. Specific ingredients account for only for only 1%1% of the variance in outcomes. of the variance in outcomes.

• Placebo effects (containing some but not all factors Placebo effects (containing some but not all factors common to many treatments) account for common to many treatments) account for 4%4% of the of the variability. variability.


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In fact . . . In fact . . .

• Relative efficacy studies have shown that the use of Relative efficacy studies have shown that the use of manuals manuals does not increase the benefits of does not increase the benefits of psychotherapy. psychotherapy.

• In fact, there are indications that strict adherence to In fact, there are indications that strict adherence to a treatment protocol may have a treatment protocol may have detrimental effectsdetrimental effects as it tends to suppresses the effect of as it tends to suppresses the effect of clinician clinician competence.competence.

• Results also suggest that training therapists to Results also suggest that training therapists to adhere to a manual can result in adhere to a manual can result in deteriorating deteriorating interpersonal relationsinterpersonal relations between the therapist and between the therapist and the client. the client.


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• There are many factors that are common across There are many factors that are common across treatment approaches that do much better in treatment approaches that do much better in accounting for variance in treatment outcome. Among accounting for variance in treatment outcome. Among these are:these are:

• working allianceworking alliance between the client and the clinician between the client and the clinician accounting for accounting for 5%5%

• clinician allegianceclinician allegiance to the treatment protocol (whatever to the treatment protocol (whatever the treatment) accounting for up tothe treatment) accounting for up to 10%. 10%.

• quality of the therapistquality of the therapist accounts for up to accounts for up to 22%22%

* This is similar to similar to previous findings * This is similar to similar to previous findings by . . .by . . .


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Miller, S. D., Duncan, B. L., & Hubble, M.A. (1997) Miller, S. D., Duncan, B. L., & Hubble, M.A. (1997) Escape from Babel: Toward a Unifying Language for Escape from Babel: Toward a Unifying Language for Psychotherapy PracticePsychotherapy Practice. W. W. Norton & Company, . W. W. Norton & Company,

New York & LondonNew York & London

A summary of the findings:A summary of the findings:

• Extratherapeutic events, accounting for Extratherapeutic events, accounting for some some 40%40% of positive outcome 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 Tx40%Relation30%Placebo15%Method15%


. . .based on 40 years of empirical and clinical research . . .based on 40 years of empirical and clinical research that facilitate positive change in clients regardless of the that facilitate positive change in clients regardless of the therapeutic approach.therapeutic approach.

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Wampold & colleagues Wampold & colleagues concluded . . .concluded . . .

A A Common Factors (or Contextual) ModelCommon Factors (or Contextual) Model does a does a better job of explaining therapeutic change than the better job of explaining therapeutic change than the Medical Model. Medical Model.

See also: Rosenzweig, S. (1936), Smith and Glass See also: Rosenzweig, S. (1936), Smith and Glass (1977)(1977)

It may be that support for a treatment protocol It may be that support for a treatment protocol containing a set of factors provides support for containing a set of factors provides support for other protocols also containing these factors. other protocols also containing these factors.


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The common factors modelThe common factors model

The Common Factors Model of psychotherapy The Common Factors Model of psychotherapy stipulates that there is a stipulates that there is a common set of factorscommon set of factors across treatments that result in a successful across treatments that result in a successful treatment outcome. treatment outcome.

In fact, results are emerging for . . .In fact, results are emerging for . . .


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. . . the equivalency of both . . . the equivalency of both empirically- validated and informed empirically- validated and informed

treatments in fluency disorderstreatments in fluency 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 to 14 relapse one year following treatment for children aged 9 to 14 years. 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 programs. therapy on stuttering: Evaluating three therapy programs. Paper presented to the IALP Congress, Brisbane. Paper presented to the IALP Congress, Brisbane.

• Franken, M. C., Van der Schalk, C. J., & Boelens, H. (2005). Franken, M. C., Van der Schalk, C. J., & Boelens, H. (2005). Experimental treatment of early stuttering: A preliminary study, Experimental treatment of early stuttering: A preliminary study, Journal of Fluency DisordersJournal of Fluency Disorders, 30, 189-199., 30, 189-199.

• Herder, C. Howard, C., Nye, C., & Vanyckeghem, M. (2006). Herder, C. Howard, C., Nye, C., & Vanyckeghem, M. (2006). Effectiveness of behavioral stuttering treatment: A systematic Effectiveness of behavioral stuttering treatment: A systematic review and meta-analysis. Contemporary Issues in review and meta-analysis. Contemporary Issues in Communication Science and Disorders, 33, 61-73.Communication Science and Disorders, 33, 61-73.


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Effect of speech therapy on stutteringEffect of speech therapy on stutteringComparing three therapy programsComparing three therapy programs

Wendy J. HuinckHerman F.M. Peters

University Medical Center Nijmegen, Dept. of Otorhinolaryngology, the Netherlands

2004 IALP Congress29 August to 2 September 2004, Brisbane, Australia


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Three treatment programsThree treatment programs(adults)(adults)

1. Fluency shaping group therapyCSP (The Comprehensive Stuttering Program

2. Stuttering modifying group therapyDM (Doetinchemse Methode)

3. Individualized Stuttering therapy VSN (Vereniging Stottercentra Nederland) pre therapy

Data CollectionData Collection: a. Pre therapy b. Post therapy c. Follow up 1 (one year after therapy) d. Follow up 2 (two years after therapy)


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ResultsResults

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)


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Herder et al. (2006)Herder et al. (2006)(adults)(adults)

• From 1798 articles, 12 met inclusion criteriaFrom 1798 articles, 12 met inclusion criteria (random assignment + experimental & control group)(random assignment + experimental & control group)

• Typical participant: Typical participant: 18-year-old male, one hr Tx for 12.5 18-year-old male, one hr Tx for 12.5 weeks; Tx- behavioral, time-out, desensitization, DCMweeks; Tx- behavioral, time-out, desensitization, DCM

• Absolute efficacy of .91Absolute efficacy of .91• Relative efficacy of .21Relative efficacy of .21• Conclusion:Conclusion:

“ “ . . . the critical element(s) for successful intervention might . . . the critical element(s) for successful intervention might not lie with the intervention itself (p. 70) but in the common not lie with the intervention itself (p. 70) but in the common element(s) found in many treatment approaches.”element(s) found in many treatment approaches.”


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In addition, the common factors In addition, the common factors model is . . .model is . . .

• Less dogmatic than the Less dogmatic than the medical modelmedical model concerning specific ingredients. concerning specific ingredients.

• Allows eclecticism as long as there is a rationale Allows eclecticism as long as there is a rationale that underlies treatment and that rationale is that underlies treatment and that rationale is cogent, coherent, and psychologically based cogent, coherent, and psychologically based (Empirically informed or validated).(Empirically informed or validated).

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


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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 the Success may be more likely to occur if both the client and the clinician share a similar view of the client and the clinician share a similar view of the process and the objectivesprocess and the objectives

• In fact, Ahn & Wampold suggest that people In fact, Ahn & Wampold suggest that people seeking help would be well advised to search for seeking help would be well advised to search for particular particular cliniciansclinicians rather than particular rather than particular treatmentstreatments


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Options for the clinicianOptions for the clinician

• Be a student of your fieldBe a student of your field——don’t rely on a don’t rely on a treatment packagetreatment package

• Employ empirically informed approachesEmploy empirically informed approaches• Understand Understand WHYWHY something works something works• Experiment with principles that fit the personExperiment with principles that fit the person• Work the program, calibrate to and follow the clientWork the program, calibrate to and follow the client• Model experimentation & alternative explanationsModel experimentation & alternative explanations

• Be curious, cautious of dogma and the “rhetoric of Be curious, cautious of dogma and the “rhetoric of pseudoscience”pseudoscience”


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

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Transcript of 1 CHAPTER 6 CHAPTER 6 Facilitating the Therapeutic Process Copyright 2010 Delmar, a part of Cengage...