Stuttering Therapy for
Children: What Makes Therapy
Work?
Patricia M. Zebrowski, Ph.D.,
CCC-SLP
University of Iowa
The Great Therapy Debate: Different Fields,
Same Questions.
•
What therapy approach “works best?”
• What is the evidence?
• Are there different kinds of evidence?
• If so, do they receive equal weight in treatment
planning?
• How does evidence translate into clinical practice?
Evidence-Based Practice
Evidence-based practice is the integration of
the best research evidence with clinical
expertise and client values.
1. ‘best research’ = ‘outcomes research’ or
clinically relevant research into the
accuracy, precision, and efficacy of
diagnostic tests and treatments
The Technique
Evidence-Based Practice
2. ‘clinical expertise’ = the ability to use
our best clinical skills and past
experience to identify delay or
disorder, appropriate intervention, and
the client’s personal values and
expectations
The Clinician
Evidence-Based Practice
3. ‘client-values’ = the unique
preferences, concerns and
expectations each client brings to the
clinical experience
The Client
What Can We Learn from Psychotherapy
Research?
• Numerous studies have compared the
effectiveness of different therapeutic
approaches for depression, anxiety,
schizophrenia, etc.
• Many of these investigations consisted of
meta-analyses of the efficacy of various
types of therapy (e.g. Wampold, Mondin, Moody,
Stich, Benson & Ahn, 1997).
What Can We Learn from Psychotherapy
Research?
• With rare exception, research has uncovered
little significant difference among different
psychotherapeutic approaches.
• This observation has been described as “the
dodo effect” (e.g. Tallman & Bohart, 2004).
“Everybody has won and all must have prizes”
- Lewis Carroll
Explaining the “Dodo Effect”
• Different therapy approaches use dissimilar
strategies or processes to achieve the same
outcome
• Research methods may not be sensitive enough
to detect differences in therapeutic effectiveness
among approaches OR differences are so subtle
that they cannot be observed using conventional
between-group designs
Explaining the “Dodo Effect”
Studies of treatment efficacy do not provide
objective descriptions or operational definitions
of therapy protocol (i.e., client-centered).
Studies of treatment efficacy do not provide the
quantitative information to allow for inclusion in
meta-analysis
There are common factors throughout all
therapies that facilitate change or progress.
Explaining the “Dodo Effect”
It is the similarities, rather than the
differences, between approaches that
account for the observation that all
psychotherapeutic approaches are, in
general, effective.
Explaining the “Dodo Effect”
These similarities can be collapsed
into four factors or elements that are
common to all forms of
psychotherapy:
•
•
•
•
Technique
Extratherapeutic Change
Therapeutic Relationship
Hope or Expectancy
The Common Factors
• Techniques – factors or ‘strategies’ unique
to different therapy approaches (e.g. “easy
onset”, “voluntary stuttering”)
• Extratherapeutic Change – characteristics
of the client and his/her environment (e.g.
temperament, social support)
The Common Factors
• Therapeutic Relationship – characteristics of the
clinician and client (and family) that facilitate
change and are present regardless of clinician’s
therapy orientation (i.e. ‘technique’).
Components include shared goals, agreement
on methods, means and tasks for treatment, and
an emotional bond (Bordin, 1979).
• Expectancy – Hope; sometimes thought of as
“placebo”. Improvement that results from client
(and clinician’s?) belief that treatment will help.
Explaining the “Dodo Effect”
Further….
Lambert (1992) and Asay and Lambert
(1999) reviewed the extant literature and
concluded that these factors (separate and
combined) account for most of the change
observed in therapy.
The “Common Factors” in Treatment Responsiveness
Therapeutic
Relationship
30%
Extratherapeutic
Change
40%
Expectancy
(Placebo)
15%
Technique
15%
Lambert & Bergin (1994)
Asay & Lambert (1999)
Bernstein Ratner (2005)
Franken, Kielstra-Van der Schalk & Boelens (2005)
The “Dodo” Effect in Speech and
Language Treatment Research?
Robey, R. (1998). A meta-analysis of
clinical outcomes in the treatment of
aphasia. JSLHR, 41, 172-187.
Law, J., Garrett, Z., Nye, C. (2004). The
efficacy of treatment for children with
developmental speech and language
delay/disorder: A meta-analysis.
JSLHR, 47, 924-943.
The “Dodo” Effect in Speech and
Language Treatment Research?
Gillam, R., Loeb, D., Friel-Patti, S.,
Hoffman, L., Brandel, J., Champlin, C.,
Thibodeau, L., Widen, J., Bohmah, T.,
Clarke, W. (2005). Randomized
comparison of language intervention
programs. ASHA.
The “Dodo” Effect in Speech and
Language Treatment Research?
• Treatment better than no treatment
• On average, treatment is effective
• Different effect sizes most likely due to
client characteristics, “age” or severity of
problem, clinician skill-level, differences in
social validity for individual clients, and so
forth.
The “Dodo” Effect in Speech and
Language Treatment Research?
• Further research to support the conclusion
that in general, “therapy works” would
waste resources.
• Future work should aim toward testing
focused hypotheses (i.e., client
characteristics + clinician skill + treatment
approach).
Robey, 1998
The “Dodo” Effect in Stuttering
Treatment Research?
• Limited data available on efficacy of
stuttering therapy for either children or
adults.
• Studies have shown that in general,
treatment is better than no treatment.
• Primary dependent variable is % stuttered
words or syllables.
The “Dodo” Effect in Stuttering
Treatment Research?
Emerging evidence that betweentreatment comparisons yield
nonsignificant findings (Lidcombe
compared to Demands-Capacities)
- Franken, Kielstra-Van Der Schalk
& Boelens (2005)
AND…..
The “Dodo” Effect in Stuttering
Treatment Research?
Recent meta-analysis of the results from 12
studies of behavioral stuttering treatment
revealed that intervention for stuttering results in
an overall positive effect. Additionally, the data
show that no one treatment approach for
stuttering demonstrates significantly greater
effects over another treatment approach.
- Herder, Howard, Nye & Vanryckehgem (2006).
The “Common Factors” in Treatment Responsiveness
Therapeutic
Relationship
30%
Extratherapeutic
Change
40%
Expectancy
(Placebo)
15%
Technique
15%
Lambert & Bergin (1994)
Asay & Lambert (1999)
Bernstein Ratner (2005)
Franken, Kielstra-Van der Schalk & Boelens (2005)
Treatment for School-Aged
Children Who Stutter
TECHNIQUE
Making Speech Change
• Exploring Talking and Stuttering
• Changing Talking
• Changing Stuttering
• Choosing Tools: What and When
Exploring Talking
• In order to understand and feel what s/he does during stuttering, the
child must know how we talk
– Establishes common terminology between child and clinician
– Develops understanding of how we coordinate respiration,
phonation & articulation for speech (i.e. “speech helpers”)
– Reinforces that his/her speech system is “normal”; i.e. NOTHING
NEEDS TO BE ‘FIXED’
• Rationale for this step
– Starting treatment in a way that is removed from emotion: neutral
and objective
– Encouraging child to approach something that he/she fears and
is used to avoiding
Exploring Talking
Purpose of exploring talking and stuttering is
to experiment with choices for:
– Changing speech
• Tools for changing airflow, tension, voicing,
movement, rate
WHICH LEADS TO…
– New ideas about speaking, for example:
• I don’t have to keep using the same patterns of
speaking
• I have options for speaking and for stuttering
Exploring Stuttering
• Identify aspects of stuttering
– In order to change behavior, need to know when and
what to change
• Exploring stuttering ties information from exploring
talking to child’s own behavior/speech patterns
• Desensitizing
Exploring Stuttering: How do you
stutter?
• Disfluency and stuttering represent difficulty
in connecting sounds, syllables and words.
Given that,
• Attend to where you are “disconnecting” and
what you are doing. What needs to be done to
“move forward” and smoothly connect
sounds, syllables and words while speaking?
• The same principles are used to both initiate
and maintain ‘easy’ speech, and to produce
‘easier’ stuttering
Tools For Change
Changing Talking
• Soft starts/easy onsets/light contacts
• Changing rate
Changing Stuttering
• Voluntary stuttering
• Holding & tolerating a moment of stuttering
• In-block corrections/pullouts
• Post-block corrections/cancellations
Changing Talking
Soft Starts/Easy Onset and
Light Contacts
• What are they?
– Slower, physically relaxed speech initiation
– Decreased muscle tension and less tense articulatory
constriction (e.g. bilabial closure, tongue-alveolar
contact)
• Why use them?
– Help initiate smooth airflow, voicing, and physically
relaxed, smooth articulator movement
• When to use them?
- Beginning of phrases or utterances
- Phrase boundaries
Changing Talking:
Changing Rate
• What is it?
– Slower speech overall: fewer syllables or words per minute
– Should sound smooth and connected, not choppy
• Why use it?
– It’s fluency enhancing because it…
•
•
•
•
Helps child attend to what he/she is doing
Gives more time to process
Gives child time to make changes in complex motor coordination
Helps child feel changes in muscle tension
• How can rate be changed?
– Stretching sounds or syllables
– Phrasing and pausing
– Combining stretches with phrasing/pausing
Changing Stuttering:
Deliberate (or Voluntary) Stuttering
• What is it?
– The child stutters “on purpose”, choosing when and how
• Why use it?
–
–
–
–
–
–
Can be used to teach any aspect of changing and varying stuttering
Assists in building awareness of stuttering moments
Decreases fear and avoidance of stuttering
Desensitizes to listener reactions
Creates a feeling of confidence in the ability to say feared words
Confront what might otherwise be avoided
• When and how to use it?
–
–
–
–
Prelude to using “pullouts”
Begin teaching at the single word level with unfeared sounds or words
Begin using it in unfeared situations
Build to use on feared words or in feared situations
Changing Stuttering:
Holding & Tolerating A Moment of Stuttering
• What is it?
– Staying in a moment of stuttering
– Child continues speech “movement” rather than stopping,
“backing up”, or otherwise using “reactive” speech strategies
• Why use it?
– Increases child’s awareness of what he/she is doing during the
stuttering moment
– Helps reduce avoidances
– Is desensitizing
• When and how to use it?
– After child can identify when and how he/she is stuttering
– Clinician HAS to be supportive and encouraging as the child is
holding the stuttering moment
Changing Stuttering:
Pullout
• What is it?
– “Holding on” to the stuttering moment and “staying with it”
– Helps to focus in on site of physical tension and cessation of
movement so as to
- Change the stuttering moment through reducing or “easing off”
tension and slowly moving ahead into the next sound or word
• Why use it?
– Confront the stuttering moment and “take charge”
(desensitization)
– Release tension and keep speech moving forward
– Reinforce a looser or “easier” way of stuttering
• When and how to use it?
– When the child experiences a high degree of
emotionality or feels “stuck” in a moment of
stuttering
– After the child has learned to “hold onto” a
moment of stuttering and tolerate it
– Start with deliberate or “fake” stuttering at the
single word level
Changing Stuttering:
Cancellation
• What is it?
– Finishing a stuttered word then
– Pausing for a moment to plan (e.g. pantomime or
silently revisit the word) then
– Stuttering on the word again in an easier way
• Why use it?
– The child learns to “cancel out” or replace hard
stuttering with a looser, more controlled form of
stuttering
– Cancellation discourages avoidance behaviors such
as recoiling, changing words, stopping in a block and
backing up
– Cancellation reinforces easier stuttering and build
confidence
– When and how to use it?
• Child MUST complete the hard stutter before
pausing and making it easier
• If the child is unable to pullout or missed the
opportunity to use a pullout, this will provide
another opportunity to learn to stutter more easily
and build confidence
• Typically used in the therapy room only as a way
of learning a strategy, not in the outside world
Disclosure
• What is it?
– Child chooses to openly acknowledges own stuttering
to listeners
• Why use it?
–
–
–
–
Allows the child to take control of the situation
It promotes openness about using techniques
Helps listeners know what to expect
Informs listeners what the client wants them to do
• When to use it?
– Like other tools, it should occur in a hierarchy (e.g.,
family, friends, group therapy, teachers/co-workers,
strangers)
– At the beginning of a conversation or presentation
Treatment for Pre-School Children
Who Stutter
TECHNIQUE
Patterns of Unassisted Recovery
• Probability of recovery highest from 6-36
months post onset
• Majority of children recover within 12-24
months post onset
• Period of recovery marked by steady
decrease in sound/syllable and word
repetitions and prolonged sounds over
time, beginning shortly after onset
• Relatively brief beginning and ascending
phase, and a relatively long declining
phase
• Subgroup of children presenting with
“severe” stuttering at onset, with
frequency of behaviors peaking at 2-3
months post onset and full recovery seen
by 6-12 months
Recovery Predictors
• Described by Yairi and associates
(1992,1999, 2005), and others (Conture,
2004; Pellowski & Conture, 2002;
Zebrowski, 1991)
• Onset before age 3
• Female
• Measurable decrease in sound/syllable and
word repetitions, and sound prolongations,
overtime, observed relatively soon postonset
• No family history of stuttering or a family
history of recovery
• No coexisting phonological problems (and
possibly language and cognitive
problems?)
****ALL ARE PROBABILITY INDICATORS****
We suspect that a child is either
stuttering or at risk for developing a stuttering
problem if (s)he meets BOTH of the following
criteria:
• Produces THREE (3) or more WITHINWORD speech disfluencies per 100 words
of conversational speech (i.e.,
sound/syllable repetitions and/or sound
prolongations)
• Parents and/or other people in the child’s
environment express concern that the child
either stutters or is a stutterer.
• After Johnson, Williams, Conture and
others
Parent-Child Interaction Therapy (PCIT)
(Millard, Nicholas & Cook, 2008)
• Rooted in “multifactorial” model of early stuttering
•Collaborative, flexible approach tailored to individual family
•Stuttering is openly discussed and acknowledged with child
• Tools based on (a) child assessment, (b) parent interview, and
(c) guided observation of videotaped parent-child play
to determine physiological, linguistic, environmental or
psychological factors
Parent-Child Interaction Therapy (PCIT)
(Millard, Nicholas & Cook, 2008)
Session 1
- Clinician feedback from evaluation and ‘discovery’ while
watching videotape.
- Management and Interaction tools are chosen.
- “Special Time” is negotiated.
Parent-Child Interaction Therapy (PCIT)
(Millard, Nicholas & Cook, 200
Session 1
Management Tools:
managing child and parent anxiety about stuttering
coping with sensitive children
confidence building
behavior management (e.g. sleeping, eating,
turn-taking, tantrums, etc.)
Parent-Child Interaction Therapy (PCIT)
(Millard, Nicholas & Cook, 200
Session 1
Interaction Tools:
Reduce speech rate;
Increase duration of turn-taking pauses;
Reduce amount of talking and length/complexity
of utterances;
Decrease language demands (i.e. vocabulary, grammar,
amount of talking, “performance” requests)
Parent reduces “time pressure” in daily
routine, and “communicative time pressure”
in verbal interaction with child
Decrease time pressure in daily life
Parent-Child Interaction Therapy (PCIT)
(Millard, Nicholas & Cook, 200
Session 1
Interaction Tools During Play:
Follow child’s lead during play and verbal
interaction (less physically active role);
Reduce instructions and questions (use comments
instead);
Maintain attention with eye contact, showing interest,
encouragement and praise
Reduce language demands (i.e. vocabulary, grammar,
amount of talking, “performance” requests)
Parent-Child Interaction Therapy (PCIT)
(Millard, Nicholas & Cook, 2008)
Session 2
Videotape parent-child play and observe use
of selected interaction tools and their effectiveness;
Parent taught to observe relationship between
child “stressors” (internal and external) and fluency,
and modifies/manipulates when possible
Provide feedback sheets and schedule weekly parent
visits
Lidcombe
(Onslow, Packman & Harrison, 2003)
www.fhs.usyd.edu.au/asrc
Parent provides treatment following training
by clinician
Spontaneous fluency is reinforced, instances
of stuttering are highlighted through parent
request to “say it easy.” (Similar to
‘cancellation?’) Ratio of praise to request for
“do-over” @ 5:1
Lidcombe (cont’d)
Parent provides treatment in daily intervals of
increasing length and communicative
complexity.
Parents taught to rate stuttering frequency
and severity, and keep daily ratings of each
for self and clinician.
EXTRATHERAPEUTIC
CHANGE
CHILD STRENGTHS
• “Signature Strengths”
• Temperament and Resilience
• Self-Perception of Control and
Competence
• Phonological Abilities
Positive Psychology
www.ppc.sas.upenn.edu
What’s RIGHT with
you?
“Signature Strengths”
- Seligman, 2002
• An important construct in “Positive
Psychology”
• (www.authentichappiness.org)
• Are seen across cultures
• Are psychological traits seen across
different situations over time
“Signature Strengths”
- Seligman, 2002
• Are valued in their own rite
• Can be acquired and measured
• Contribute to adaptive coping
- Curiosity, interest in the world
- Love of learning
- Judgment, critical thinking, openmindedness
- Ingenuity, practical intelligence
- Emotional intelligence
“Signature Strengths”
- Seligman, 2002
- Perspective
- Bravery
- Perseverance
- Integrity, honesty
- Kindness, generosity
- Loving, and allowing oneself to be
loved
- Citizenship
- Fairness
- Leadership
“Signature Strengths”
- Seligman, 2002
- Self-control
- Discretion
- Humility
- Appreciation of Beauty
- Gratitude
- Optimism
- Sense of Purpose
- Forgiveness
- Humor
- Enthusiasm
Temperament
• A largely inherited, multi-faceted construct
that characterizes a child’s general
disposition and range of moods
(Goldsmith, 1987)
• Reactivity – excitability of the nervous
system to behavioral responses or
external stimuli
• Self-regulation – the processes that
inhibit or facilitate reactivity (for
example, attention, approachavoidance strategies, etc.)
• Activity – lethargic to hyperactive
• Emotionality – emotional response to new or
novel stimuli
• Sociability – comfort in being alone as
opposed to being with other
Temperament mediates the influence of the
environment on the child.
The “Behaviorally Inhibited”
(BI) Child
• Described by Kagan (1984; 1994) as
one type of normal temperamental
profile
• Relatively timid, sensitive to
environment and own behaviors, higher
levels of reactivity and lower thresholds
for excitability than other children
• Based on results from administration of
the Temperament Characteristic Scale
(TCS) and the Parent Perception Scale,
Oyler (1996a, 1996b) and Oyler and
Ramig (1995) determined that young
children who stutter were significantly
more behaviorally inhibited and less
likely to take risks than children who do
not stutter.
• Further, Anderson, Pellowski, Conture &
Kelly (2003) used similar measures and
observed that children who stutter are
less adaptable, less rhythmic in
physiological functioning, and less
distractible than their nonstuttering
peers.
Resilience
• Children who are successful at regulating
excitability and emotional reactivity exhibit
resilience.
• Children are described as resilient when
their temperament and related adaptive
skills (or personality traits) facilitate the
ability to “bounce back”, or take negative
experiences (e.g. stuttering) in stride.
Resilience
• Resilient children may exhibit a more dominant
(i.e. less timid), extraverted and sociable
personality, and are inclined to readily and
positively approach social situations, including
therapy.
• May display a relatively high degree of
attentional focusing and risk-taking in therapy
and in social (communication) situations.
• Temporal substrate of rhythmicity may benefit
from practice effects in therapy.
• All may contribute to progress in therapy OR
unassisted recovery.
Teaching Resilience
Penn Resiliency Project curriculum
(http://www.ppc.sas.upenn.edu/prpsum.htm)
Fishful Thinking
(www.fishfulthinking.com)
The Optimistic Child (Seligman, 1995)
Teaching Resilience
Seven ingredients to teach children:
• Emotion awareness and control
• Impulse control
• Realistic optimism (i.e. explanatory style)
• Flexible thinking
• Self-efficacy
• Empathy
• Reaching out (i.e. risk taking)
Teaching Resilience
Emotion Awareness and Control
- Coping – listen and value; relaxation;
guided imagery.
- Link between thoughts and feelings
What I think
How I feel
What I feel in my body
What I do
(Cook & Botterill, 2009)
Teaching Resilience
- “Two sides” of the coin can be true.
- My thinking side and my feeling side.
- What does my “wise brain” know?
(Scott, 2009)
Teaching Resilience
- Desensitization through:
Talking about talking and stuttering
Identification and “holding on” to the
moment of stuttering (i.e. changing
stuttering)
“Stutter buddy”
Class presentation
Teaching Resilience
Impulse Control
- Notice, breathe and pause
Realistic Optimism
- Explanatory Style (optimistic/pessimistic)
- Learned Optimism (Seligman, 1998)
- ABCDEs (Adversity, Belief, Consequence,
Disputation/Distraction, Evidence)
Teaching Resilience
A: “I stuttered when I said my name.”
B: “She’ll think I’m stupid”; “I can’t do anything
right”; “I shouldn’t talk when I meet someone.”
C: “I felt embarrassed and frustrated”;
D: “She’s really nice”; “People don’t really care
when I stutter”; “She still wanted to talk to me
even though I stuttered”
E: “I have a lot of friends”; “I can talk in class, and
have good things to say.”
Teaching Resilience
“Learned optimism works not through an
unjustifiable positivity about the world, but through
the power of “non-negative” thinking.”
(Seligman, 1998)
Teaching Resilience
Flexible Thinking
- Notice, breathe and pause
Realistic Optimism
- Explanatory Style (optimistic/pessimistic)
- Learned Optimism (Seligman, 1998)
- ABCDEs (Adversity, Belief, Consequence,
Disputation/Distraction, Evidence)
Teaching Resilience
Empathy
- Provide opportunities for altruism
- “View from two windows”
- Service/learning projects
Self-Perception of Control and
Competence (Self-Efficacy)
• Research in youth sport participation has
shown that internal locus of control =
higher self-perception of competence, and
vice versa (i.e. external locus of control).
• Internal locus of control serves as a
protective factor in children who exhibit
high levels of trait anxiety or
abuse/neglect.
Self-Perception of Control and
Competence
• Internal locus of control characterizes
children who are motivated to engage in a
particular activity or learning task, and
maintain a high level of interest across
time (e.g. therapy).
• Equivocal evidence that internal locus of
control facilitates short-term gains in
stuttering therapy.
Phonological Abilities
• Evidence suggests that children who stutter
are more likely to exhibit (co-existing)
phonological delay or disorder when
compared to their nonstuttering peers (Louko,
Edwards and Conture, 1990; Paden and
Yairi, 1996; Paden, Yairi and Ambrose, 1999;
Paden, 2005).
AND…
Phonological Abilities
• Comparisons of children who recover
from, and persist in, stuttering show that
the persistent group are more likely to
achieve poorer scores across a number of
tests of phonological proficiency (Paden
and Yairi, 1996; Paden, Yairi and
Ambrose, 1999; Paden, 2005).
Phonological Abilities
• Some children who stutter may exhibit
developmental asynchronies (Watkins,
Yairi and Ambrose, 1999; Watkins,
2005), perhaps contributing to a lower
threshold for perturbation or disruption.
FURTHER…
Phonological Abilities
• Children who stutter who have ageappropriate phonology and speech
articulation are more likely to
experience a positive therapy outcome
that is attained relatively quickly.
• Young children close to onset with no
co-occurring phonological problems are
more likely to experience unassisted
recovery.
PARENT STRENGTHS
• “Signature Strengths”
• Congruence
• Able to Shift the Parenting Perspective
• There are human strengths that act as buffers
against mental illness: courage, futuremindedness, optimism, interpersonal skill,
faith, work ethic, hope, honesty,
perseverance, the capacity for flow and
insight, to name several.
(www.authentichappiness.org)
Emotional Responses
•
Parents will often have an emotional
response(s) to their child’s stuttering.
•
Emotions are important to uncover as
they can influence the way parents
cope with the child and his stuttering.
Emotional Responses
•
•
•
•
•
•
Grief
Feelings of inadequacy
Anger
Guilt
Feelings of vulnerability
Feelings of confusion
Coping Strategies
•
•
•
•
Fight or Flight
Modification
Reframing
Stress Reduction
Coping: A Wellness Perspective
(Holland, 2007)
• Positive Psychology is the study of strength
and virtue. Treatment is not just fixing what is
broken; it is nurturing what is best.
• Positive Psychology does not rely on wishful
thinking, faith, self-deception, fads, or handwaving; it tries to adapt what is best in the
scientific method to the unique problems that
human behavior presents.
• There are human strengths that act as buffers
against mental illness: courage, futuremindedness, optimism, interpersonal skill,
faith, work ethic, hope, honesty,
perseverance, the capacity for flow and
insight, to name several.
(www.authentichappiness.org)
Congruence
• Congruence helps parents to respond to a
situation with both intellect (rational
intelligence) and emotion.
• An idealized situation that is difficult to attain.
• As people, we all need to work continually to
attain congruence; as clinicians, we want to
help our clients to attain it.
• Different styles of internal organization
- high or low in intellect
- high or low in affect
• High intellect: focus on facts; deny or
repress emotions
• High affect: difficulty in processing
information
• We want to help a parent who is
intellectually oriented to gain
access to and express feelings
• We want to help a parent who is
affect oriented to express feelings
so he/she can begin to process
information
Counseling Microskills (Ivey, 1994)
• Specific communication skills that help
clinicians interact more intentionally with
clients
• Microskills form the foundation of
interviewing and obtaining information in
all interactions
Counselor Response: Determining the
Course of the Interaction
•
Content response
•
Counterquestion
•
Affect response
•
Reframing
Counselor Response: Determining the
Course of the Interaction
•
Sharing self
•
Affirmation
• High affect
listen and value, recognizing they
have options, focus on process,
relaxation, stay in the now, give
assignments to bind up anxiety
• High intellect
microskills to recognize feelings
Able to Shift the Parenting
Perspective
• “Fix” or “force” vs. “ally and advocate”
• Refocus comes about through:
- planned communication
- objective understanding
- active acceptance
THERAPEUTIC RELATIONSHIP
• Characteristics of clinician that facilitate
change
• Child and Family Education and
Preparation
• Attending to the Child’s and Parent’s
“Theory of Change”
Attributes and Behaviors of the
Counselor That Facilitate Listening and
Valuing
•
•
•
•
•
•
•
Client-centered
Accepting
Concerned and empathetic
Relaxed and calm
Does not interfere or impede
Does not judge
Does not suggest or give answers
• Does not deny feelings
• Absence of self-focus – paralysis vs.
oblivion
• No noticeable disinterest
• Tolerates silence
• Avoids superficial content
• Appropriate topic change
• Listens and attends
• Appropriately reinforcing
• Generates warmth and trust
• Tolerates crying
• Accepts emotional language
(adopted from Luterman, 2001;
Shames, 2000)
Child and Family Education and
Preparation
• Limited understanding of clinical process
OR mismatch between child and family
expectations and realities encountered
leads to poor therapeutic relationship
AND
• Puts child and family at greater risk for
dropping out of therapy
Child and Family Education and
Preparation
• Child and family will respond positively to
treatment when engaged in an exploration
of various topics, including:
- nature of stuttering
- contemporary theories of etiology
- why children come for therapy
- the general structure of therapy
- some specifics of behavior change
Child and Family Education and
Preparation
- what will be taught and why
- the importance of active participation
- self-expression
- trust and confidentiality
- child, parent and clinician roles and
responsibilities
- examples of positive outcomes and
how they were achieved
Child and Family Education and
Preparation
Coleman, D. & Kaplan, M. (1990).
Effects of pretherapy video preparation on
child therapy outcomes. Professional
Psychology: Research and Practice, 21(3),
199-203.
Attending to the Child’s and
Parent’s “Theory of Change”
“Within the client is a theory of change
waiting for discovery, a frame-work for
intervention to be unfolded and
accommodated for a successful outcome”
(Hubble, Duncan & Miller, 1999)
Attending to the Child’s and
Parent’s “Theory of Change”
• What ideas do you have about what needs to
happen for improvement to occur?
• 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?
- Hubble, Duncan & Miller, 1999
Attending to the Child’s and
Parent’s “Theory of Change”
• How does change usually happen in your life?
• What do you do to initiate change?
• What have you tried to help with stuttering so
far? Did it help? How did it help? Why didn’t it
help?
- Hubble, Duncan & Miller, 1999
Attending to the Child’s and
Parent’s “Theory of Change”
• Each client and family presents the clinician with
a new theory to learn and a new, client-directed
intervention to suggest.
• Research in psychotherapy has shown that what
the client and family want from treatment, how
these goals are accomplished , and their
perception of improvement may be the most
important factors in therapy.
HOPE or EXPECTANCY
• Pathways Thinking
• Agency Thinking
• “Expectancy Theory”
Hope or Expectancy
The positive emotion that stems from the
ability to successfully engage in both
pathways and agency thinking is the
essence of hope. Hope is not a purely
emotional phenomenon; it is an emotional
response that is rooted in cognition.
- Barnum, Snyder, Rapoff, Mani & Thompson, 1998).
Hope or Expectancy
• “Expectancy Theory” – With hope for
change comes expectancy that change
can and will take place. An individual’s
belief that a certain
treatment will yield a
Hope or Expectancy
certain effect either triggers or correlates
to that effect.
• Expectancy Theory has long been used to
explain the placebo effect in medicine.