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TRANSCRIPT
The “Meaning Response” as Applied to Stuttering Therapy
John A. Tetnowski, Ph.D., CCC-SLP, BRS/M-FDKathleen Scaler Scott, M.S., CCC-SLP, BRS/M-FD
Jack S. Damico, Ph.D., CCC-SLP, BRS/M-FDUniversity of Louisiana at Lafayette
The history behind this project…
A little bit of magic fairy dust?
The impact of meaning upon stuttering therapy success
• What is truly meant by the placebo effect?• What is the meaning response?• What studies support the meaning response?• How does knowing this help us to plan treatment?• How does knowing this help us to plan future
research?
The placebo effect…reinterpreted (Moerman, 2002)
• Originally understood as changes produced by an inert therapeutic condition, i.e. a placebo
• Conflict in definition because placebos are inert• If something is inert, it causes no change or effect• But yet placebos are said to cause a change or
effect
The meaning response(Moerman, 2002)
• “Psychological and physiological effects of meaning in the treatment of illness” (Moerman, p. 14)
• Positive effects include most of the things known as the placebo effect; negative effects include most of the things known as the nocebo effect (both are meaning based)
• It also includes things that are not traditionally part of the placebo effect (active vs. inert meds)
Studies Supporting the Meaning Response
• Meaning response results from interaction with a perceived healing context– Physical changes (Lanza, Goff, Scowcroft, Jennings, & Greski-Rose,
1994)
– Brand name has an effect upon pain reduction of aspirin and placebo (Braithwaite & Cooper, 1981)
– What doctors know makes a difference (Gracely, Dubner, Deeter, & Wolskee, 1985)
– How strongly doctors believe in the effectiveness of treatments makes a difference (Uhlenhuth et. al, 1966)
– “Skeptics can heal 30% to 40% of their patients with inert medication, while enthusiasts can heal 70% to 90%” (Benson & McCallie, 1979)
Studies Supporting the Meaning Response
– Form of treatment has an impact upon healing• Color pill and its intended purpose (Blackwell, Bloomfield &
Buncher, 1972)• Number of pills (Blackwell, Bloomfield & Buncher, 1972)• Pill vs. Shot in U.S. (de Craen, Tijssen, de Gans, & Kleijnen,
2000)—in Europe less of an effect• Surgery works even if not real (Thomsen, Bretlau, Tos, &
Johnson, 1981)• Placebo has an effect upon pain reduction only if patient
knows it’s happening (Benedetti, 1996)• Response varies with culture (Lock, 1986)
Current Trends in the field of Stuttering…
• Client-centered focus (Rogers, 1946)– Clinician involvement in self-help groups (Reeves, 2006;
Yaruss et al., 2002)
– Clients as “consumers” (Reeves, 2006; Yaruss & Quesal, 2004a;
Yaruss & Quesal, 2004b)
– Consumer role on advisory boards and credentialing organizations
– Call for research partnership between clinicians, researchers, consumers (Yaruss & Quesal, 2004a; Yaruss & Reeves, 2002; Yaruss et al., 2001 )
Current Trends in the field of Stuttering…
• Consumer needs haven’t changed, but our response to them has…– Changes in what researchers are willing to study– Health insurance payments for alternative approaches
(Cleary-Guida, Okvat, Oz, & Ting, 2001)
– Client perspective studies on recovery (Finn, 1996; Finn,
Howard & Kubala, 2005), treatment (Plexico, Manning &
DiLollo, 2005), role of support groups (Trichon, 2006; Yaruss et al., 2002)
Current Trends in the field of Stuttering…
• Multifactorial theory of stuttering and implications for treatment (Smith, 1999; Smith & Kelly, 1997)
• What works for a client– One therapy?– Combinations of therapy?
• Depends upon what each means for a client
To understand what’s meaningful to a client…
• Constructivism: Meaning shaped by the interaction of language and experience in client’s life (Vygotsky 1934, 1986)
• Meaning is socially constructed (Berger & Luckman, 1966)– Lock (1986)– de Craen et al. (2000)
To understand what’s meaningful to a client…
• What’s meaningful for a CLIENT and for an SLP in terms of therapy is initially shaped by:– Culture (home environment, education system)– Background– Experiences
• And is further shaped by:– Experiences (Kamhi, 1994)
– Interactions with others (Yaruss & Quesal, 2004a)
• An SLP example…
So what does this say about therapy?
• Skeptics and how we present approach really matters (Lidcombe & Speecheasy examples)
• Form of treatment may make a difference– High technology vs. low technology– Ongoing vs. intensive– Individual vs. group
So what does this say about therapy?
• Who administers the treatment may make a difference…but it all depends upon the consumer’s perspective of each scenario– Specialist vs. non-specialist– Master’s vs. Ph.D.– New clinician vs. experienced clinician– Person who stutters or not
• A client example
Clinician-Client Congruence (Manning, 1999): Am I aware of what my belief system is?
“Maybe rather than asking which treatment strategy is best, we should be asking the infinitely more complex question of why a particular strategy or technique might be best for
a certain clinician, for a particular client, at a specific time” (Manning, p. 128)
– Increased progress when patient and doctor are in agreement (Starfield et. al, 1981)
• Congruence leads to comfort• Comfort leads to confidence
What about the “true believer”?
• Role of clinician confidence and the meaning response– How strongly doctors believe in the effectiveness of treatments
makes a difference (Uhlenhuth et al., 1966)– “Skeptics can heal 30% to 40% of their patients with inert
medication, while enthusiasts can heal 70% to 90%” (Benson & McCallie, 1979)
– Kamhi (1994)“Being a true believer allows you not to ‘slip into the tentacles of relativism’, but needs to be flexible to realize that there may be more than one way to teach something” (p. 197)
Within confidence lies our socially constructed view of effectiveness…
• What does effectiveness mean to you as a clinician?– Elimination of stuttering?– Communicating without avoidance?
• If you witness success through an approach that is not congruent with yours, what are you left feeling skeptical about?
Within confidence lies our socially constructed view of effectiveness…
If our approach is not congruent with our definition of success, it becomes difficult to exude the level of confidence necessary to
evoke the meaning response in our clients.
• If you use and are confident in a singular approach, this may not be an issue.
• If you are focused on client-centered therapy, you must have confidence in the client’s ability to drive the therapy and the approaches to a certain extent. (A real life example)
An approach to therapy vs. a therapy approach…
Strupp (1986)…Four Elements to Effective Psychotherapeutic
Process
• Guided by a theory
• Therapist creates and maintains interpersonal context
• Therapist seeks to understand meaning behind client’s behavior
• Therapist attempts to reformulate meaning in a way for client to use it productively
What does this look like?
• Narrative therapy (Neimeyer, 1995)
• Cognitive restructuring
• Fluency Shaping approach
• Stuttering Modification approach• The Lidcombe Program (Onslow & Packman, 1999)
Narrative Therapy
CognitiveRestructuring
Fluency Shaping
StutteringModification
Lidcombe
Theory X X X X X
Interpersonal X X ? X X
Understand Meaning
X X - X -
Reformulate Meaning
X X - X -
So what does this say about therapy?
• Perhaps any approach will work if it is grounded in theory
• But we must consider the meaning of it for the client, because this is the bottom line– If fluency shaping means to a client, “I should
avoid stuttering at all costs”, avoidances may remain
– If stuttering modification means to a client, “I can never have complete fluency”, motivation may decrease (ex. with adolescents)
So what does this say about therapy?
• Your confidence in the method and your expression of this confidence can have a significant impact upon progress (this may be a case for specialist vs. non-specialist)
• If you must project confidence and believe in some theory, then you need congruence between therapist and approach
So what does this say about therapy?
• The meaning response is triggered by what the client values—this should help guide your choice of approach (Seligman, 1995)
• Brand names, such as specialists, may make a difference just from perception
• Putting someone on a waiting list and giving them suggestions is in fact some type of meaning-based treatment—this has significant implication for spontaneous recovery rates of preschoolers
So what does this say about therapy?
• Form of treatment may make a difference– Length of Therapy– Number of sessions per week– Meaning of form will tend to vary by culture
So what does this say about therapy?
• Grounding in a theory is important, but what theory is less important
• Experience may be less important if other components are there—however, experience may bring things like grounding in theory
So what do I do Monday morning with my clients?
• Know your paradigm and be flexible within it• Ground your approach in theory—not trial and
error• Use an approach you can justify and have
confidence in• Project your confidence in the approach• Be there with your clients—listen and understand
their needs
So what do I do Monday morning with my clients?
• If you are a skeptic about the approach the client wants, you may want to consider sending them to someone else…but on the other hand…if you are flexible within your paradigm, this can work if you can…
• Be flexible and move your ego out of the way
So how do we establish meaning?
• Have client journal things like…– What do you think the reasoning is behind what
you’re working on in therapy?– What lesson/message do you take away from the
activities we’re working on?– What does fluency mean to you?– What does stuttering mean to you?– What are your perceptions of your fluency skills?
How about research?
• We need to look at the meaning effect closely and examine its impact upon stuttering therapy outcomes
• Compare the psychotherapy research with that of stuttering therapy, following the methods of Strupp (1986) – Ethnographic interviews with successful therapists
from all paradigms to find out the basic principles they follow in therapy
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