Ego-States and Measures of Fluency: Unraveling Connections to Treatment
Outcome
William S. Rosenthal Department of Communicative Sciences and DisordersCalifornia 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
Figure 1. Changes in Ego States for Low and High Treatment Success Groups (N=32)
-3
-2
-1
0
1
2
Adult AdapChld
NatChld
NurtParent
CritParent
Ego States (See text for descriptions)
Dif
fere
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e S
co
res
fro
m
Pre
to
Po
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Th
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Low Success
High Success
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 MeasuresWords/Min Total
WordsSD Change ID Change CB Change
Pre Rx Mean 94.02 187.5 10.79 12.7 3.77
SD 33.61 70.67 8.53 8.77 1.67
Post Rx Mean 110.17 219.4 8.29 5.93 2.16
SD 31.66 60.54 8.29 4.78 1.30
t= -2.649 -2.629 1.585 4.290 5.362
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 andSpeech 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/Min Total Words SD Change ID Change CB Change
High Success M 23.6 49.7 -5.12 -8.36 -1.9
(N=21) SD 37.25 72.77 9.26 10.19 1.91
Low Success M 2.0 -2.0 2.50 -3.74 -1.05
(N-11) SD 24.03 46.08 5.78 4.92 1.06
t= -1.733 -2.134 2.479 1.736 1.379
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 StatesWords/Min Total Words SD Change ID Change CB Change
Adult .354 .394 .179 .235 .315
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
Constant R F Ratio of R
STEP 5
Nurturing Parent .495168 .775765 .7986 8.6126
Total Words .00302
Stuttering Disfluency .039491
Indeterminate Disfluency .039695
Behavioral Concomitants .202075
STEP 9
Adult -.243372 .7184432 .8136 4.7868
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.
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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.
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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