1. The National Stuttering Association Scottsdale, AZ - 2009 Walt Manning, Ph.D. Walt Manning, Ph.D. School of Audiology & Speech-Language Pathology The University of Memphis wmanning@memphis.edu Common factors for successful therapy Clinician factors & principles of change

2. Wampold, B. (2001). The great psychotherapy debate: models, methods and findings. Lawrence Erlbaum: Mahwah, NJ Basic goal: to explain the factors that contribute to an over-riding theory (meta-theory) that best accounts for successful treatment outcomes in counseling & psychotherapy. Basic goal: to explain the factors that contribute to an over-riding theory (meta-theory) that best accounts for successful treatment outcomes in counseling & psychotherapy. Closely related to fluency treatment Closely related to fluency treatment

3. Wampold’s Findings Measures of absolute efficacy (treatment vs no treatment): Measures of absolute efficacy (treatment vs no treatment):  effect size of.80  a large effect in the social sciences  Consistent findings across studies of many different treatment approaches that psychotherapy is remarkably efficacious.

4. Wampold’s Findings Measures of relative efficacy (comparisons of different treatments): Measures of relative efficacy (comparisons of different treatments):  Effect size of.20  inconsequential effect theoretically or clinically Differences between treatments appear to be inflated by the effectiveness of the clinicians delivering the therapy. Differences between treatments appear to be inflated by the effectiveness of the clinicians delivering the therapy.

5. Wampold’s Findings Found little support for the medical model for explaining treatment outcomes Found little support for the medical model for explaining treatment outcomes specific ingredients account for only 1% of the variance in outcomesspecific ingredients account for only 1% of the variance in outcomes Placebo effects account for 4% of the variabilityPlacebo effects account for 4% of the variability

6. Furthermore... The use of manuals does not increase the benefits of psychotherapy. The use of manuals does not increase the benefits of psychotherapy. Strict adherence to a treatment protocol may have detrimental effects as it tends to suppresses the effect of clinician competence. Strict adherence to a treatment protocol may have detrimental effects as it tends to suppresses the effect of clinician competence. Adherence to a manual can result in a deteriorating therapeutic relationship. Adherence to a manual can result in a deteriorating therapeutic relationship.

7. So how to explain success? Factors that are common across treatment approaches do much better in accounting for variance in treatment outcome. Factors that are common across treatment approaches do much better in accounting for variance in treatment outcome. The working alliance between the client and the clinician accounted for up to 5%The working alliance between the client and the clinician accounted for up to 5% Clinician allegiance to the treatment protocol (whatever the treatment) accounted for up to 10% Clinician allegiance to the treatment protocol (whatever the treatment) accounted for up to 10% The quality of the therapist accounted for up to 22%The quality of the therapist accounted for up to 22%

8. Previous authors & researchers had predicted this outcome: Rosenzweig, S. (1936) Smith & Glass (1977) Miller, S. D., Duncan, B. L., & Hubble, M.A. (1997)

9. In addition the common factors model... is less dogmatic than the medical model concerning specific ingredients.is less dogmatic than the medical model concerning specific ingredients. allows eclecticism as long as there is a rationale that underlies treatment and that rationale is Empirically informed or validatedallows eclecticism as long as there is a rationale that underlies treatment and that rationale is Empirically informed or validated emphasizes the healing context and the meaning attributed to it by the participants (both therapist and client).emphasizes the healing context and the meaning attributed to it by the participants (both therapist and client).

10. From: Ahn & Wampold (2001) meta-analysis of component studies in counseling and psychotherapy. Journal of Counseling Psychology, 48, 251-257. success may be more likely to occur if both the client and the clinician share a similar view of the process and the objectives success may be more likely to occur if both the client and the clinician share a similar view of the process and the objectives people seeking help would be well advised to search for particular clinicians rather than particular treatments people seeking help would be well advised to search for particular clinicians rather than particular treatments

11. Similar findings now occurring for fluency disorders Hancock, K., & Craig, A. (1998). Predictors of stuttering relapse one year following treatment for children aged 9 to 14 years. Journal of Fluency Disorders, 23, 31–48. Hancock, K., & Craig, A. (1998). Predictors of stuttering relapse one year following treatment for children aged 9 to 14 years. Journal of Fluency Disorders, 23, 31–48. Huinck, W. J. & Peters, H. F. M. (2004). Effect of speech therapy on stuttering: Evaluating three therapy programs. Paper presented to the IALP Congress, Brisbane. Huinck, W. J. & Peters, H. F. M. (2004). Effect of speech therapy on stuttering: Evaluating three therapy programs. Paper presented to the IALP Congress, Brisbane. Franken, M. C., Van der Schalk, C. J., & Boelens, H. (2005). Experimental treatment of early stuttering: A preliminary study, Journal of Fluency Disorders, 30, 189-199. Franken, M. C., Van der Schalk, C. J., & Boelens, H. (2005). Experimental treatment of early stuttering: A preliminary study, Journal of Fluency Disorders, 30, 189-199. Herder, C. Howard, C., Nye, C., & Vanyckeghem, M. (2006). Effectiveness of behavioral stuttering treatment: A systematic review and meta-analysis. Contemporary Issues in Communication Science and Disorders, 33, 61-73. Herder, C. Howard, C., Nye, C., & Vanyckeghem, M. (2006). Effectiveness of behavioral stuttering treatment: A systematic review and meta-analysis. Contemporary Issues in Communication Science and Disorders, 33, 61-73.

12. The essential structure of an effective therapeutic interaction An effective therapeutic interaction is characterized by the development of a therapeutic alliance between the client and clinician from which the client feels empowered and is able to autonomously engage in agentic behavior leading to cognitive change. As a result, the client becomes a more effective communicator with greater fluency. Implicit in such therapeutic interaction are characteristics of clinicians that facilitate the development of the therapeutic alliance. These include being professional, passionate, committed, and confident, and understanding the nature and depth of the stuttering experience, including its treatment. Such clinicians believe in the therapeutic process and in the client’s ability to accomplish therapeutic change. They are client driven and employ clinical decision-making that accounts for the client's needs, capabilities, and personal goals. They actively listen to their clients with a patient and caring demeanor, building feelings of confidence, acceptance, understanding, trust, and a desire on the part of the client to take an active role in the treatment process. Plexico, Manning & DiLollo, ASHA 2009

13. The essential structure of an ineffective therapeutic interaction An ineffective therapeutic interaction is characterized by a failure to develop a therapeutic alliance between client and clinician, leaving clients feeling misunderstood, inadequate, shameful, discouraged, and without hope, and generating little motivation and desire to attend therapy. This often occurs due to a clinician’s dogmatic adherence to a particular therapeutic protocol and associated techniques, poor knowledge about the nature and depth of the stuttering experience, a lack of interest in the nuances of therapeutic change, poor listening skills, and inattentiveness to the client’s capabilities and goals. Such interactions often result in further negative emotions of frustration, anger, embarrassment, and guilt. Plexico, Manning & DiLollo, ASHA 2009 Plexico, Manning & DiLollo, ASHA 2009

14. Three Goals for Change * Increase fluency Improve communication Develop greater autonomy (agency) * Therapeutic & Self-Directed change

15. Agentic Agentic Behavior “Agency is thought of as the ability to live life and achieve a voice in a literal as well as a metaphorical sense; or you could think of it as having a lifestyle where the person can act for themselves and speak on their own behalf.” (Monk, G., Winslade, J., Crocket, K, & Epston, D., 1997)

16. “, in our view, has much to do with the capacity for agency and less to do with the absence of disease.” “Health, in our view, has much to do with the capacity for agency and less to do with the absence of disease.” Drewery, W., Winslade, J., Monk, G., p. 256

17. 4 Principles of Therapeutic Change Move toward rather than away from the problem Assume the responsibility for taking action Assume the responsibility for taking action Restructure the cognitive view of the self and the problem Restructure the cognitive view of the self and the problem Recruit the support of others Recruit the support of others