When I attended
a master’s degree program decades ago, I was trained that thoughtful lesson
planning guided treatment. The speech-language pathologist (SLP) wrote specific
goals and designed activities to achieve them. The activities carefully blended
fun and reward to help children enjoy the hard work of therapy. The university I
attended required that graduate students create their own therapy materials
based on current research. I was the expert.
After
graduation, I discovered beautifully made picture cards and thick ring-bound
workbooks were easy to buy, saving me hours of prep time. Glossy catalogs marketing expensive therapy materials arrived in my mail every fall. Children cooperated more easily with these commercial
products. I bought items on clearance. My colleagues encouraged me to purchase
formal tests, though quite expensive. Thus, my lesson plans were supported by
official diagnostic testing and my therapy activities super charged with
specialized teaching materials. Therapy was fun.
Then
along came “Evidence Based Practice” (EBP). I attended conferences at which professors
challenged earlier research and proclaimed a new (and nearly impossible)
standard as the only valid treatment. Data was paramount. Suddenly, the
most important thing to do in speech therapy was collect data. I spent perhaps the last 10 years reacting
to this pronouncement. I audio recorded activities, filled data grids,
photographed children’s drawings, and filled out questionnaires during sessions. I documented diagnostics, individual lessons
and long term progress… it was downright distracting. Therapy was about the numbers.
This change
in clinical process has taken place in Early Invention services. In
2004, “the intervention focus moved from engaging children in planned
educational therapy activities to supporting caregivers to embed interventions
within their typical activities/routines.” (2) This was a “major shift in
service delivery.” SLPs put down their traditional lesson plans and materials.
They adapted knowledge and skill to the individual needs of a family’s living
situation. This paradigm shift meant
the SLP’s new job description included “...(a) seeking out and respecting
caregivers’ views; (b) ensuring equal participation of family members in the
decision-making process; (c) recognizing caregivers’ rights to make decisions
even when decisions are contrary to the professionals’ views; and (d) affirming
the role of culture, values, and family beliefs in their community.” (3) This
was not easy. A study in 2007 found
“...that 51% of home visit time was spent in direct instruction with the child,
and less than 1% of the time was used to coach the caregiver.” (4) Speech
therapy had to move forward by training SLPs to coach adult learners. The article has a detailed description of 11 strategies for coaching caregivers. Speech
therapy is now all about collaboration.
I required that a parent participate
in speech therapy with their child for several years now. This reduced my caseload but ensured that
caregivers were educated about stuttering. They learned about teaching methods
and the process of change. They tailored goals to suit their children’s lives. I was letting go of the lesson plan and beginning
to view each therapy session with greater uncertainty. My job description was evolving from lesson
planner to listener. Because I was in this transition, The StutterTalk
podcast Serious Concerns about Speech Therapy for People Who Stutter in the Public Schools (9) raised the hair on the back of my neck. Taro Alexander recounted a presentation by a self-described expert who felt he had
the perfect lesson plan. Mr. Alexander and Peter Reitzes wondered aloud about what
was going on in speech therapy and why.
I
attended many conferences and workshops over the years searching for answers to
this question. Outside of formal
presentations, I heard experts comment that a specific treatment protocol
didn’t matter, it was the relationship between the client and the clinician
that determined success. I don’t recall seeing this point of view on a PowerPoint
slide. It simply floated in and out of conversations. This was confusing. I spent
much of my career writing lesson plans, buying specialized therapy materials,
collecting data, and accumulating continuing education credits. What’s all this
about how it doesn’t matter?
At
every conference, I asked for references. At the 2014 National Stuttering
Conference, one speaker told me to buy the Heart
and Soul of Change. (10) I’d heard about the role of counseling in speech
therapy and listened Dr. Luterman (11) say to put down the lesson plan. This
book explained WHY. This book proposes that something beyond therapy technique
is more important to progress. There are four common factors that seem to
account for successful change. The authors write, “In all, we found that the effectiveness of therapies resides not in
the many variables that ostensibly distinguish one approach from another.
Instead, it is principally found in the factors that all therapies share in
common.” (12)
This
book is about counseling, not stuttering. Yet experience taught me that
stuttering is not like learning to play the piano or golf or baseball or math
or science or social studies or writing. Speech therapy for stuttering is not
only about learning a motor skill or a thought process. It’s about personal transformation.
It’s about becoming a different speaker, a new identity with a new voice. When
I heard an adult stutterer and her SLP describe this as a part of her increased
fluency, I felt they had it right. (13) To
paraphrase: my speech language
pathologist and I decided what my new voice would be. This is not fluency. This is a new voice, a
new speaker, a new identity.
Back
to the Heart and Soul of Change. The
authors of this book were amazed by “the wide range of theories, therapies,
models, and approaches being promoted” at a Family Therapy Network
Symposium. So, they “decided to turn to
the clinical and research literature for answers on what matters for effective
treatment.” (14) They discovered four “common factors.” Only two – only two – of these factors
accounted for 70% of success.
1.
Client/extratherapeutic
factors: This
category consists “of the client’s strengths, supportive elements in the
environment, and even chance events. In short, they are what clients bring to
the therapy room and what influences their lives outside it…. This category
accounts for 40% of outcome variance.” (15)
2.
Relationship
factors: “These represent a wide range of
relationship-mediated variables found among therapies no matter the therapist’s
theoretical persuasion. Caring, empathy, warmth, acceptance, mutual
affirmation, and encouragement of risk taking and mastery are but a few.” This category accounts for “30% of the
successful outcome variance.” (16)
3.
Placebo,
hope, and expectancy: “These curative effects therefore are
not thought to derive specifically from a given treatment procedure; they come
from the positive and hopeful expectations that accompany the use and
implementation of the method.” p.
10 “...their contribution to
psychotherapy outcome at 15%.” (17)
4.
Model/technique
factors: “They include a rationale, offer an explanation
for the client’s difficulties, and establish strategies or procedures to follow
for resolving them….most therapeutic methods or tactics share the common
quality of preparing clients to take some action to help themselves...they
account for 15% of improvement in therapy.” (18)
One
reason for gathering client input is to establish where he is in the process of
change. The book describes nine clinical processes that coincide with different
stages of change. I can talk about the stages
of change in another article.
I’m learning to welcome more collaboration.
Family preference guides therapy. SLPs with little experience in stuttering can read about what it’s like to live with in the archived
newsletters of the National Stuttering Association and the Stuttering
Foundation. There are personal stories posted in years of International
Stuttering Awareness Day online conferences. In StutterTalk podcast (19) What I Wish My SLP Knew About Stuttering,
Elana Kahan shares what it was like to attend years of stuttering therapy as a
child.
(2) J.
J. Woods et. al. (2011) Collaborative Consultation in Natural Environments:
Strategies to Enhance Family-Centered supports and Services. Lang, Speech, Hear Serv Sch,
42: p. 381
(3) Ibid.
(4) Ibid.
(5) ASHA
Professional Development Self Study 8726 © 2011
(6) MK Clark and
P Flynn (2011) Rational Thinking in School -Based Practice, Language Speech Hearing Services in Schools,
42, p. 74.
(7) Ibid
(8)
Nickola Wolf
Nelson (2011) Questions About Certainty and Uncertainty in Clinical Practice, Lang Speech, Hearing Services in Schools,
42: see Figure 1, page 84
(9) Serious
Concerns about Speech Therapy for People Who Stutter in the Public Schools,
episode 484, www.stuttertalk.com
(10)
Mark A. Hubble, Barry L. Duncan, Scott D. Miller
(Eds.) (1999) The Heart & Soul of Change: what
Works in Therapy, Washington, DC: the American
Psychological Association
(11)
David
Luterman, Ph. D., Sharpening Your Counseling Skills, July 3, 2014, National
Stuttering Association Annual Conference in Washington DC.
(12)
Ibid p. (xxii)
(13)
K. Sabourin and E. Alpern, Why Stutter More? July 4, 2014 National
Stuttering Association Annual Conference in Washington DC.
(14)
M.A. Hubble et. al., (1999) p. xxi
(15)
Ibid. p. 9
(16)
Ibid. p. 9
(17)
Ibid. p. 9
(18)
Ibid. p. 10
(20)
M.A. Hubble et. al., (1999) p. 14