Presentation on theme: "Ego-States and Measures of Fluency: Unraveling Connections to Treatment Outcome William S. Rosenthal Department of Communicative Sciences and Disorders."— Presentation transcript:
Ego-States and Measures of Fluency: Unraveling Connections to Treatment Outcome William S. Rosenthal Department of Communicative Sciences and Disorders California State University, East Bay, Hayward, California Shannon N. Austermann Hula San Diego State University / University of California, San Diego Joint Doctoral Program in Language and Communicative Disorders, San Diego, California Liz Rud Livermore Valley Joint Unified School District, Livermore, California
Unravel: (1)to separate or disentangle the threads of a fabric (2) to free from complications (3) to take apart, destroy
A recurrent thread in stuttering research-- Is treatment success best measured by: Counts of fluency breaks Changes in social and psychological constructs such as: Increased speech output Increased social interaction Greater self acceptance
Previously, we Discussed the theoretical relationship between life scripts, ego-states, and stuttering Showed a change in ego-state over the course of successful stuttering therapy Increase in function of ego states that exercise conscious control and support change Decrease in ego state functions associated with resistance to change (Rosenthal, 2001)
Purpose of current study Compare ego-state change and objective speech measures with an independent measure of treatment outcome Estimate of the contribution of each of these constructs to treatment outcome.
Participants in the study Thirty-two (32) young adult stutterers on active duty in the military (31 males, 1 female) All participated in an 8-week intensive treatment program Age range 18 to 35, mean 24 years
Treatment outcome ratings Each participant was recorded (video and audio) at the beginning and end of treatment The two-minute spontaneous speech samples were used in this analysis Pre treatment and post treatment severity ratings used a 7 point equal appearing interval scale, from “Very Mild” to “Very Severe” Participants were divided into two subgroups: High Success (N=21) and Low Success (N=11), following procedures described previously (Rosenthal, 2001)
Treatment outcome ratings (con’t) The scale items were based on program goals (similar to Van Riper’s modification and SSMP) Indications of excessive muscle tension while stuttering, Indications of inefficiency, or undue delay in releasing tension, Attempts to avoid or postpone stuttering, Inappropriate movements while stuttering that are conspicuous and distracting, Instances of inappropriate rate associated with stuttering, Instances of failure to initiate or maintain eye contact with the camera while stuttering, and Instances of inappropriate loudness, pitch, or voice quality associated with stuttering.
Ego State Analysis Ego state strength was assessed from the visual record and from the content of transcripts of the pre- and post-therapy videos Constructs, as defined by transactional analysis theory, were used (Berne, 1961) Adult (A) Adapted Child (AC) Natural Child (NC) Nurturing Parent (NP) Critical Parent (CP)
Ego State Analysis (con’t) Ego state ratings were based on non-verbal information only (following Dusay & Dusay, 1989) Facial expressions Gestures Body posture The relative strength of each ego state assigned a score that totaled 20 points for all ego states combined
Objective Measures Adaptation of the Stuttering Severity Instrument (SSI) (Riley, 1980) For the current study Stuttering Disfluency (SD) was defined as part word repetitions, sound and syllable repetitions at the beginning of words, audible prolongations, inaudible blockages, and cessations of phonation. A separate category of Indeterminate Disfluency (ID) was established. This category included whole word repetitions (mono and polysyllabic), phrase repetitions, interjections, extraneous words, filled pauses, and stereotyped starters.
Objective Measures (con’t) Concomitant Behaviors (CB), included distracting sounds (noisy breathing, whistling, sniffing, blowing, or clicking sounds), facial grimaces (jaw jerking, tongue protruding, lip pressing, or jaw muscles tensing), head movements (moving back or forward, turning away, making poor eye contact, or constant looking around), and movement of extremities (arm and hand movement, hands about face, torso movement, leg movements, or foot tapping or swinging) (Note: The total of all types of Concomitant Behaviors exhibited throughout the speech sample was recorded, rather than the rate per number of words, as was the case with all other measures) In addition, Words Per Minute (WPM) and Total Words (TW) were counted for each of the two minute spontaneous speech samples
Ego State Changes Previously discussed in detail in the preceding paper (Rosenthal, 2001) Predictions were generally supported Successful treatment is associated with increase in Adult Ego State and decrease in Adapted Child Ego State
Overall Change in Objective Measures All measures moved in the expected direction by the end of treatment, four of the five significantly
Table 1. --Pre- and Post-Treatment Means of Various Objective Measures of Stuttering and Speech Rate: Words Per Minute, Total Words, Stuttering Disfluency (SD), Indeterminate Disfluency (ID), and Concomitant Behaviors (CB) Change Measures Words/MinTotal WordsSD ChangeID ChangeCB Change Pre Rx Mean94.02187.510.7912.73.77 SD33.6170.678.538.771.67 Post Rx Mean110.17219.48.295.932.16 SD31.6660.548.294.781.30 t=-2.649-2.6291.5854.2905.362 p.0126.0132.123<.0002<.0001 Statistically significant p values are shown in blue.
Changes Related to Treatment Outcome Increased verbal output (Total Words) for High Success Group Decreased disfluency (Stuttering Disfluency) for High Success Group
Table 2. Means, Standard Deviations, and Significance of Changes of Objective Measures of Stuttering and Speech Rate: Words Per Minute, Total Words, Stuttering Disfluency (SD), Indeterminate Disfluency (ID), and Concomitant Behaviors (CB) For High and Low Success Groups Treatment Group Words/MinTotal WordsSD ChangeID ChangeCB Change High SuccessM23.649.7-5.12-8.36-1.9 (N=21)SD37.2572.779.2610.191.91 Low SuccessM2.0-2.02.50-3.74-1.05 (N-11)SD24.0346.085.784.921.06 t=-1.733-2.1342.4791.7361.379 p.0934.0411.019.1035.178 Statistically significant p values are shown in blue.
Addressing the core question: what measures predict treatment outcome? We first looked at the relationship between objective measures and ego states Moderate positive correlation between measures of verbal output and increased Adult Ego State Moderate negative correlation between measures of verbal output and Adapted Child Ego State Moderate to moderately-high positive correlations were found for all objective measures and the independent measure of treatment success Previously showed treatment success is associated with high, pre-therapy ratings of Adapted Child (r =.48) and low loading of Adult (r = -.36)
Table 3. --Correlation (r) Between Ego States, Treatment Success and Various Objective Measures of Stuttering and Speech Rate: Words Per Minute, Total Words, Stuttering Disfluency (SD), Indeterminate Disfluency (ID), and Concomitant Behaviors (CB) Ego States Words/MinTotal WordsSD ChangeID ChangeCB Change Adult.354.3220.127.116.115 Adapted Child-.396-.435-.121-.030-.232 Natural Child.084.056-.015-.054.186 Nurturing Parent.287.299.115.101.011 Critical Parent____-.025______ 003_______-.066______.322________-.185________ Treatment Success.587.628.506.359.379 Statistically significant r-values (p<.05) are shown in blue.
A Predictive Model In the previous study (Rosenthal, 2001), we showed the predictive value of ego state change on treatment outcome. A step-wise linear multiple regression analysis was performed, with the dependent variable Treatment Success, and the independent variables the changes in Ego State Ratings from pre- to post-therapy. The variables of Adapted Child, Natural Child, and Nurturing Parent resulted in a multiple R of.57. The addition of the remaining variables did not significantly increase the predictability of treatment success.
A Predictive Model (con’t) For the present study, we conducted a similar analysis to examine the predictive relationship of objective measures on treatment outcome. That analysis showed that the variables Total Words, Stuttering Disfluency, Indeterminate Disfluency, and Concomitant Behaviors resulted in a multiple R of.71, accounting for nearly 50% of the variance attributable to treatment outcome.
A Predictive Model (con’t) Finally, we regressed all variables (ego state variables and objective variables) against treatment outcome. This resulted in a maximum R of.81 when all variables are accounted for. However, most of the variance in this model is due to a combination of all objective measures and a single ego state measure, Nurturing Parent. The corresponding multiple R is.79. The addition of the remaining ego state measures increases the predictive efficiency of the model by only 3.8%.
Table 4. --Stepwise Linear Multiple Regression with Treatment Outcome as the Dependent Variable with Steps 5 and 9 Shown. INDEPENDENT VARIABLE BETA Coefficient ConstantRF Ratio of R STEP 5 Nurturing Parent.495168.775765.79868.6126 Total Words.00302 Stuttering Disfluency.039491 Indeterminate Disfluency.039695 Behavioral Concomitants.202075 STEP 9 Adult-.243372.7184432.81364.7868 Adapted Child-.332662 Natural Child-.273851 Nurturing Parent.205564 Critical Parent-.199486 Total Words.000498 Stuttering Disfluency.050201 Indeterminate Disfluency.039335 Behavioral Concomitants.209854
A Predictive Model (con’t) Based on the regression models from the previous (Rosenthal, 2001) and current studies, we can summarize in the following way: The use of Ego State change alone accounts for approximately 32% of treatment outcome variance The use of Objective measures alone accounts for approximately 50% of treatment outcome variance The combination of Ego State change and Objective measures accounts for approximately 66% of treatment outcome variance
A Predictive Model (con’t) Objective measures emerge as the stronger predictor of treatment success, even in a treatment modality that does not emphasize fluency as a primary goal Findings are limited to this study and this particular treatment approach. Similar studies on alternative treatment modalities are needed to flesh out these relationships. Nevertheless, psychodynamic constructs, such as ego states, need to be included to complete the treatment model The latter statement suggests a need for improved training in principles of counseling and psychotherapy for speech- language pathologists in general, and fluency specialists in particular.
References Berne, E. (1961) Transactional Analysis in Psychotherapy. New York: Grove Press Breitenfeld, D.H. & Lorenz, D.R. (1989) Successful Stuttering Management Program for Adolescent and Adult Stutterers. School of Health Sciences, Eastern Washington University, Cheney, Washington. De-Nil, L.F., Kroll, R.M., & Ham, R.E. (1996) Therapy review: Successful Stuttering Management Program (SSMP) Journal of Fluency Disorders, 21, 61-67. Dusay, J.M.& Dusay, K.M. (1989) Transactional analysis. In Corsini, R.J. & Wedding, D. (Eds.) Current Psychotherapies (4th ed.) pp. 405-453. Itasca, IL: F.E. Peacock Publishers, Inc. Naylor, R.V. and Rosenthal, W.S. (1968) Clinical Investigations of Stuttering: II. Treatment and Follow-up of the Adult Stutterer. Final Report, Project No. 3A-015601A826-01-036, U.S. Army Medical Research and Development Command, Washington, D.C. Riley, G.D. (1980) Stuttering Severity Instrument for Children and Adults. Tigard, OR: C.C. Publications. Rosenthal, W.S. (1997, August) Stuttering scripts: The transactional analysis of stuttering therapy. Paper presented at the Second World Congress on Fluency Disorders. San Francisco, CA. Rosenthal, W.S. (1998) The transactional analysis of stuttering therapy: scripts and ego states. In E.C. Healy & H.F.M. Peters (Eds.) 2nd World Congress on Fluency Disorders Proceedings, San Francisco, California, 1997 (pp. 185-189). Nijmegen, The Netherlands: Nijmegen University Press. Rosenthal, W.S. (2001) Relationship of change in ego-state to outcome of stuttering therapy: preliminary findings. In H-G. Bosshardt, J. S. Yaruss & H. F. M. Peters (Eds.) Fluency Disorders: Theory, Research, Treatment and Self-Help. Proceedings of the Third World Congress of Fluency Disorders in Nyborg, Denmark, 2000 (pp. 405-409). Nijmegen, The Netherlands: Nijmegen University Press. Van Riper, Charles (1973) The Treatment of Stuttering. Englewood Cliffs, N.J.: Prentice Hall
Acknowledgements This research was supported, in part, by an RCSA Faculty Grant from the California State University. Sandra Cullinan, Carol A. Murphy, and Vanna Sivilay Nicks served as raters for some of the data analyses cited in the present study, and that were reported in a preceding paper. Some of the data in this report were first presented at the Annual Convention of the American Speech-Language-Hearing Association, November 2001, New Orleans, LA
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