Common Factors

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.

 I imagined a backlash to this kind of clinical process was at work when I read a recent e-newsletter from attachment parenting international (1).  The January 28th blog post was titled Parents need to be the compass point. By example it reported the following: “A mother recently told me that she met with her son’s teacher, guidance counselor and school psychologist. She wanted to explain that it was important that her son’s teachers develop a caring relationship with him. When she explained to them what her son needed, their response was, ‘You’re only the mother.’ In other words, ‘We are the professionals who know best what students need.’” The blog article encouraged parents to defend themselves against this attitude. Attachment parenting recognizes that parents are their “child’s compass point, guide, comforter and safe home base.” How can therapy welcome collaboration with families?

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.

 A recent continuing education course invited me to re-evaluate once again what goes on in therapy. (5) The title of the course is Balancing Certainty and Uncertainty in Clinical Practice. Children are unique human beings who can’t be defined by the certainty of data points. Every new day is a creative process filled with uncertainty. Given this reality, how might we move forward in speech therapy? The seven articles in this course debated rational thinking as a guiding principal. “Rational, team-based thinking uses a balance of certainty and uncertainty to arrive at decisions that are likely to have a positive impact on student performance. Collective thinking helps to frame problems as uncertainties for which appropriate solutions can be found." (6) Rational thinking depends upon conversation. It’s not a solitary activity. It’s not about an SLP sitting alone in an office carefully crafting lesson plans. This conversation is referred to as generative dialogue. “In generative dialogue, student-centered problems (e.g., behavior, learning difficulties) are reframed as uncertainties that are explored to reveal underlying principles of teaching that apply to all learners.” (7) Decision making becomes a process involving teachers, students, and parents defining mutual goals. (8)

            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.

 Therapy is not about the SLP dictating a therapy program and manipulating client compliance. It’s about how the “Clients’ own generative, self-healing capacities allow them to take what different therapies have to offer and use them to self-heal.”  (20) Therapy is about partnership balanced by certainty and uncertainty. It's about discovering the benefits of change.


(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
(19)           www.stuttertalk.com February 24, Episode 497,
(20)           M.A. Hubble et. al., (1999) p. 14

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