stuttering therapy: what needs to change and who decides? · stuttering that have led them to...

Stuttering Therapy: What Needs to Change and Who Decides?

Patricia Zebrowski, Ph.D., CCC-SLPProfessor Emerita

Department of Communication Sciences and Disorders

The University of Iowa

U.S.A

Background 2

• Older children and teenagers who stutter often pose unique clinical challenge:

• Lengthy therapy history and poor goal attainment • Teens experience relatively high rate of relapse (32-70%)

(Craig, 1998)

• Potential explanations?

• The adolescent’s inability or unwillingness to actively engage in therapy is typically considered evidence of “lack of motivation,” and clinicians may discontinue treatment until the teen “is ready”

Reframing “Motivation” as “Readiness to Change”

• ”Motivation” can be reconceptualized as “readiness” to change –a dynamic psychological state.

• Readiness to change emerges when ambivalence toward change is resolved.

• Two major sources of ambivalence toward change include (1) lack of clarity about what one want to change, and why it is important, and (2) self-confidence that change can be maintained in difficult situations or following failure

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• Teenagers may come to therapy with partially formed notions of why they are there, and what they want. They may have vague feelings and ideas about stuttering that have led them to decide that they want to make some kind of change.

• For example, they may tell the therapist that they want to change the way they talk, but what is more important to them is to change they way they think and feel about stuttering – or the way their parents think and feel.

The Essential Clinical Question: What Needs to be Changed and Why?

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• They may be contemplating some kind of change to which they are not yet ready to commit (Proschaska, DiClemente, & Norcross, 1992).

• We propose that durable treatment outcomes in stuttering therapy for teens occur when therapy tools are matched with the adolescent’s readiness to use them.

Motivation = Readiness to Change

AND

Readiness is a dynamic psychological state that can be facilitated by the therapist

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The therapist’s role is to facilitate the patient’s expression of the pros and cons of making a change,

and to gently guide him or her to an acceptable resolution (Rollnick & Miller, 1995).

EVERYONE has the potential to change AND we are all experts about ourselves

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Understanding How We Change:The “Stages of Change” Model • The Stages of Change or Transtheoretical model is an

integrative model of intentional behavior change that considers readiness to be the result of a temporal progression of stages that are predicted by shifts in cognition.

• Arose from “common factors” orientation that the patient aand his/her environment contribute more to change than therapy techniques or approach.

The “Common Factors” in Treatment Responsiveness

Therapist-ClientAlliance30%

ExtratherapeuticChange – Clientand Family Strengths and Challenges 40%

Technique15%

Expectancy(Placebo)15%

Lambert & Bergin (1994)Asay & Lambert (1999) 8

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+–

Pre-Contemplation Contemplation

+ –

Preparation

+–

Action Maintenance

The Stages of Change Model(Prochaska & DiClemente, 1983)

Hall & Rossi (2008); Mauriello et al. (2007)

Readiness to change is viewed as a temporal progression through a series of stages. Research with multiple clinical populations has shown that both stage placement andmovement predicted by shifts in decisional balance and situational self-efficacy

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Decisional balance

Dynamic conflict resolution as a result of considering the pros and cons of making a change and its consequences

Situational self-efficacy

Confidence in one’s ability to sustain a behavior change in difficult situations or following failure

Precontemplation

• Precontemplators typically don’t see the solution because they can’t see the problem.

• Resist change; denial and avoidance are common defenses.

• Often are demoralized: they feel their situation is hopeless.

Contemplation

• Begin to acknowledge and understand problem, seek solutions.• Likely far from making actual commitment to

action: may have indefinite plans for ‘the next six months or so’.• Fear of failure may keep them searching for a more

complete understanding or generating more solutions.• Transition to Action marked by focus on solution

rather than the problem, and thinking about the future more than the past.

Preparation

• Planning to take action within the next month; making the final adjustments before beginning to change behavior

• May appear committed/ ready for action but have not yet resolved their ambivalence

• Resolution of ambivalence increases chance of successful change

Action• Overt modification of

behaviors and surroundings; changes are more visible to others during this stage• Efforts to maintain this

action are most important; action does not equal change

Maintenance

• Actively working to maintain change, prevent lapses/ relapses• Indefinite; may last from as short as 6 months to a

lifetime

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+–

Pre-Contemplation Contemplation

+ –

Preparation

+–

Action Maintenance


Hall & Rossi (2008); Mauriello et al. (2007)

Two Ways of Assessing and Supporting Change Readiness in

Teenagers Who Stutter

Part I: Does the stages of change model fit the population of teenagers who stutter

Part II: Does motivational interviewing, a process used by behavioral health physicians and counseling psychologists facilitate decisional balance and situational self-efficacy in adolescents who stutter?

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Part I

Applying the Stages of Change Model Among

Adolescents who Stutter

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Collaboration & Support

This project is supported by:

A clinical research grant from the American Speech-Language Hearing Foundation

This project is a collaboration between:

University of IowaStuttering Research Lab

University of Rhode IslandCancer Prevention Research Center

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Purpose9

To develop and test the validity of new scales to assess the core constructs of adolescents’ readiness to manage stuttering• Stage of change• Decisional balance• Situational self-efficacy

Zebrowski, P., Rodgers, N. & Gerlach, H. (accepted pending revision). Readiness for change among adolescents who stutter: Application of the Transtheoretical Model of intentional behavior change. American Journal of Speech-Language Pathology.

Method: 4-Step Process1. Conducted focus groups and individual interviews with

adolescents who stutter and SLPs who specialize in stuttering to unpack the construct “stuttering management”

2. Qualitatively analyzed recorded transcripts to develop items for each of the three scales

3. Administered these scales online to 286 adolescents who stutter (13-21 years old)

4. Conducted confirmatory factor analyses to (a) assess model fit and (b) eliminate overlapping items and those with low factor loadings for each of the three scales

Stage of Change “What would an adolescent be doing if they were managing stuttering?”

Decisional Balance “What are the good things (pros) and not-so-good things (cons) about managing stuttering?”

Situational Self-Efficacy “What are some speaking situations in which stuttering is difficult to manage?”

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Stage of Change Scale11

“The best way to help with stuttering is to:1. Learn and use speech strategies or techniques for speaking more fluently

and/or stuttering with less tension and struggle;2. Change negative thoughts and feelings about stuttering; and 3. Say what you want to say without avoiding sounds, words, or situations.

“It’s important to pay attention to all three of these things because just focusing on one may not enough to make long-lasting changes in the way you talk. For any of these things to become automatic, you will need help and regular practice for up to one year or more.

“Thinking about the three things above, how ready are you right now to do something about your stuttering?

I am not thinking about doing any of these things in the next 6 months.I am thinking about doing one or more of these things in the next 6 months.I am planning to do one or more of these things in the next month.I have been doing one or more of these things for LESS than 6 months.I have been doing one or more of these things for MORE than 6 months.

PreCont.Cont.Prep.

ActionMaint.

5.6%11.2%11.2%14.3%57.8%

12“Thinking of these three ways to manage your stuttering one by one…




PreCont.Cont.Prep.

ActionMaint.

PreCont.Cont.Prep.

ActionMaint.

PreCont.Cont.Prep.

ActionMaint.

13.0%13.0%15.4%11.1%47.5%

8.0%13.0%15.4%16.0%47.5%

9.9%13.6%19.1%16.7%40.7%

2. How ready are you right now to change your negative thoughts and feelings about stuttering?

3. How ready are you right now to say what you want to say without avoiding sounds, words, or situations?

1. How ready are you right now to get help to learn and use speech techniques for speaking more fluently or stuttering with less tension and struggle?

Decisional Balance Scale13

“When thinking about making a change to your stuttering, how important is it to you if…?”

PROS FactorLoading

you would feel better about yourself .85

you would talk more .81

you would feel calmer .77

you could just be yourself .76

you would feel a sense of accomplishment .74

you would worry less about talking .72

you wouldn’t feel like stuttering runs your life

.71

people would treat you just like any other person

.69

CONS FactorLoading

your speech would sound and feel weird and unnatural to you

.76

you would lose part of who you are if you stuttered differently

.76

other people would disapprove of you trying to change the way you speak

.75

you wouldn’t feel like yourself if you stuttered differently

.72

your speech would sound weird and unnatural to other people

.72

you would be disappointed in yourself if you change the way you speak just to make other people happy

.64

you may miss out on other activities to spend time working on your stuttering

.52

you might not be able to change the way you speak

.45

1 2 3 4 5Not at all important Extremely important

Situational Self-Efficacy Scale14

“How sure are you that you can do something about stuttering when…?”

CHALLENGING SITUATIONS FactorLoading

you are talking in front of a group of people .86

you are talking to a teacher .78

you are ordering in a restaurant .77

you are being interviewed for a job .76

you are telling a story .74

you are meeting new people .74

you are introducing yourself .74

it is a hard talking day .71

you are feeling stressed out .70

you are calling someone on the phone .70

you are afraid you are going to stutter .69

1 2 3 4 5Not at all sure Extremely sure

Summary of Main Findings• The 5-factor model fit our data, suggesting that the Stages of Change

Model can be applied to adolescents to determine how ready they are to manage stuttering

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Pre-contemplation Contemplation Preparation Action Maintenance

best predicted by decisional balance (pros/cons)

and self-efficacy

• “Stuttering management” among adolescents is comprised of 3 interdependent components:

1. Strategies for speaking more fluently/stuttering with less tension

2. Changing negative thoughts/feelings about stuttering

3. Speaking without avoidance

• In our sample, stage of change was best predicted by decisional balance (specifically, the weight of the pros) for overall stuttering management

Using What We Know Now…

• A style of interpersonal interaction that facilitates client’s readiness to change and compliance with therapy participation.

• Rooted in the therapist’s ability to LISTEN and skill in initiating and maintaining a direct, constructive and neutral discussion about behavior change and how it can be achieved.

(Rollnick & Miller, 1995; Behrman, 2006)

• Collaborative – not the same as ‘patient centered’ approach, but instead focusing on specific behavior change that is needed

• Evocative – ‘what’s right with you’ focus to activate resources for achieving personal goals

• Honors patient autonomy – requires detachment and recognition that people make choices about their lives.

(Rollnick et al; 2008)

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Motivational Interview: DARN

• Desire – “What do you want?” and theory of change• Ability – “What is possible?”• Reasons – “What are benefits?”• Need – “How important is this change?” (1-10)

(Rollnick et al; 2008)

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• DESIRE: • What would you like to see different about

stuttering? What makes you think you need to

change?

• Are others concerned about your stuttering?

• Why do you think others are concerned about your

stuttering?

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• What ideas do you have about what needs to happen?

• 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?

• How do you think stuttering has affected your life (1=not at all; 10=it affects me every day)

• What would need to happen for you to move that number close to “1”?

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• If our work together is successful and you could say “Wow, I’m glad I worked on this because I’m doing much better”, what would you be doing differently, or what would be changed about yourself?

• How would others know that something has changed? What would they notice that was different?

• ABILITY• Self-efficacy: Confidence in the ability to use a new

behavior and remain engaged following failure

• EX: On a scale of 1-10, how confident are you that you will be able to manage your stuttering in the next week (or month)? • When your schedule gets busy? • When you don’t feel well? • When you have worked hard for a period of time and

don’t feel better about stuttering?

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• ABILITY• What are you doing that makes you rate your

confidence as (high number)? • What would it take to move from a (number) to a

(higher number)?• How would life be different if you moved from a

(number) to a (higher number)?• What do you think you might do to increase your

confidence about exercising?

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• Think of another time in your life when you wanted to learn something, or change something. What did you do? What happened?

• Who are the people you do or could turn to for help or understanding (draw support system). How does each of these people help and support you?

• What are you good at? What do friends and family say you are good at?

• REASON

• What would be the good things about changing something about your stuttering?

• What would be not so good about changing ?

• What will happen if you don’t change?

• What will your life be like three years from now if you changed what you are doing about stuttering? ?”

DECISIONAL BALANCE

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• NEED

- How important is making this change?- How important are the pros and cons?

1 (not at all important) – 10 (extremely important)

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• The changes I want to make are:• The most important reasons why I want to make

these are:• The steps I plan to take in changing are:• The ways other people can help me are:• I will know that my plan is working if:• Some things that could interfere with my plan are:• What I will do if the plan isn’t working:

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Case Study: John

• 13-year-old boy

• Stuttering severity (SSI-4): moderate

• Overall Assessment of the Speaker’s Experience with Stuttering (OASES): moderate-to-severe overall life impact

• Participates in regular weekly speech therapy at school• Primary focus: practicing stuttering modification strategies in the

therapy room

• Motivational interviewing is “a collaborative, person-centered form of guiding to elicit and strengthen motivation for change” (Miller & Rollnick, 2009, p. 137)

• Rooted in the therapist’s ability to LISTEN

• Focuses on eliciting and maintaining client “change-talk”• Desire: “Why do you want to make a change?”• Ability: “If you decided to make a change, what

strengths would help you succeed?• Reason: “What are three good reasons for you to change?”• Need : “What makes you think that you need to change?”

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Motivational Interviewing

(Rollnick & Miller, 1995; Behrman, 2006)

I am not thinking about doing any of these things in the next 6 months.I am thinking about doing one or more of these things in the next 6 months.I am planning to do one or more of these things in the next month.I have been doing one or more of these things for LESS than 6 months.

✓ I have been doing one or more of these things for MORE than 6 months.

I am not thinking about doing any of these things in the next 6 months.I am thinking about doing one or more of these things in the next 6 months.

✓ I am planning to do one or more of these things in the next month.I have been doing one or more of these things for LESS than 6 months.I have been doing one or more of these things for MORE than 6 months.

I am not thinking about doing any of these things in the next 6 months.I am thinking about doing one or more of these things in the next 6 months.I am planning to do one or more of these things in the next month.

✓ I have been doing one or more of these things for LESS than 6 months.I have been doing one or more of these things for MORE than 6 months.

PreCont.Cont.Prep.

ActionMaint.

PreCont.Cont.Prep.

ActionMaint.

PreCont.Cont.Prep.

ActionMaint.

2. How ready are you right now to change your negative thoughts and feelings about stuttering?

3. How ready are you right now to say what you want to say without avoiding sounds, words, or situations?

1. How ready are you right now to get help to learn and use speech techniques for speaking more fluently or stuttering with less tension and struggle?

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Decisional Balance Scale20

“When thinking about making a change to your stuttering, how important is it to you if…?”

PROS Rating

you would feel better about yourself 4

you would talk more 5

you would feel calmer 4

you could just be yourself 4

you would feel a sense of accomplishment 3

you would worry less about talking 4

you wouldn’t feel like stuttering runs your life

1

people would treat you just like any other person

3

CONS Rating

your speech would sound and feel weird and unnatural to you

1

you would lose part of who you are if you stuttered differently

5

other people would disapprove of you trying to change the way you speak

1

you wouldn’t feel like yourself if you stuttered differently

3

your speech would sound weird and unnatural to other people

1

you would be disappointed in yourself if you change the way you speak just to make other people happy

3

you may miss out on other activities to spend time working on your stuttering

2

you might not be able to change the way you speak

2

1 2 3 4 5Not at all important Extremely important

Situational Self-Efficacy Scale21

“How sure are you that you can do something about stuttering when…?”

CHALLENGING SITUATIONS HOW SURE…

you are talking in front of a group of people 3

you are talking to a teacher 4

you are ordering in a restaurant 5

you are being interviewed for a job 4

you are telling a story 4

you are meeting new people 1

you are introducing yourself 2

it is a hard talking day 4

you are feeling stressed out 3

you are calling someone on the phone 1

you are afraid you are going to stutter 4

1 2 3 4 5Not at all sure Extremely sure

Processes of Change(Prochaska & Velicer, 1997)

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Helping Relationships – utilize social support(e.g., participate in support group, create a diagram of support system)

Stimulus Control – manage the environment(e.g., manipulate daily schedule to increase

communication opportunities)

Counter-Conditioning - substitute unhealthy behaviors for healthy behaviors(e.g., replace or pay less attention to negative thoughts using mindfulness/CBT)

Reinforcement Management – incorporate rewards for healthy behaviors

(e.g., group recognition, parent training)

Consciousness Raising – increase awareness about stuttering causes, treatments, other facts

(e.g., bibliotherapy)

Dramatic Relief – pay attention to and release feelings

(e.g., watch videos of others stutter, role-playing)

Environmental Re-evaluation – notice if and how stuttering affects others(e.g., family conversations about stuttering, watch

stuttering documentaries)

Self Re-evaluation – develop a more positive self-image and build self-worth

(e.g., values clarification, imagery)

Self Liberation – increase belief and commitment to change, often through public testimonies

(e.g., self-disclosure activities, educating others)

Social Liberation – notice public support(e.g., secure accommodations, self-advocacy)



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Pre-contemplation Contemplation

Consciousness Raising – increase awareness about stuttering causes, treatments, other factsExample: Bibliotherapy (Gerlach & Subramanian, 2016)

Adults who stutter who participated in a qualitative study on outcome of reading and discussing amemoir during therapy sessions reported the following outcomes:• Normalized specific stuttering experiences• Revisiting negative experiences related to stuttering promoted a positive perspective shift• Helped clients realize they could change their negative thoughts and feelings• Helped clients realize that healthier ways of coping with stuttering exist

Dramatic Relief – pay attention to and release feelingsExamples: CHAIR ACTIVITY?? TONY DILLO?Watch videos of others stuttering, Role-playing

Environmental Re-evaluation – notice if and how stuttering affects othersExamples: Family conversations about stuttering, Watch stuttering documentaries

Social Liberation – notice public supportExamples: Learn about and secure accommodations, Improve self-advocacy


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Contemplation Preparation

Self Re-evaluation – Develop a more positive self-image and build self-worthExample: Narrative Therapy: Values clarification (DILLO BOOK CITE)

Example: Narrative Therapy: Imagery (DILOLLO BOOK CITE)• Unique possibility questions


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Helping Relationships – utilize social supportExamples: Participate in a support group, Create a diagram of support system

TRICHON STUDY

Counter-Conditioning - substitute unhealthy behaviors for healthy behaviorsExamples: Replace or pay less attention to negative thoughts using mindfulness and CBT techniques

HARLEY STUDY


Examples: Self-disclosure activities, Educating others

BYRD studies

Preparation Action


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Stimulus Control – manage the environmentExamples: Manipulate daily schedule to increase communication opportunities

Reinforcement Management – incorporate rewards for healthy behaviorsExamples: Group recognition, Parent training

Action Maintenance

Helping Relationships – utilize social supportExamples: Participate in support group, Create a diagram of support system

Counter-Conditioning - substitute unhealthy behaviors for healthy behaviorsExamples: Replace or pay less attention to negative thoughts using mindfulness and CBT


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Questions?

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stuttering therapy: what needs to change and who decides? · stuttering that have led them to...

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