An Eclectic Social-Cognitive Behavioural Model for Stuttering Treatment Mark Meersman Lecture Symposium ECSF KU Leuven Association "Stuttering. The Nature... the Treatment" Lessius, Antwerp, Belgium 2008, April 18 th
Overview ESCB stuttering treatment The essence... Rationale metatheoretical assumption: biopsychosocial model a three-factor aetiological model treatment goals Methodology experimental design the clinical flow chart cognitive behaviour therapy Assessment as setting up explanatory hypotheses Treatment as testing hypotheses Treatment as the selection and implementation of behaviour modification procedures ESCB stuttering treatment & EBP Conclusions Mark Meersman. Lessius Antwerp: Symposium Stuttering. 2008, April 18-19 2 / 34
The essence... apply the ability to LEARN modify speech-/language-/fluency- BEHAVIOUR treatment = testing hypotheses procedures tailored to the client biopsychosocial model Mark Meersman. Lessius Antwerp: Symposium Stuttering. 2008, April 18-19 3 / 34
Rationale No scalpel, no medication... only... BEHAVIOUR! Tools = knowledge (on communication, disorders, fluency, stuttering ) logopedic methodology NOT just a collection of techniques! based on biopsychosocial view on communication and communicative problems Mark Meersman. Lessius Antwerp: Symposium Stuttering. 2008, April 18-19 4 / 34
Rationale > biopsychosocial model International Classification of Functioning, Disability and Health: ICF-model (WHO, 2001) Health Condition (disorder/disease) Body function&structure (Impairment) Activities (Limitation) Participation (Restriction) Environmental Factors Personal Factors Mark Meersman. Lessius Antwerp: Symposium Stuttering. 2008, April 18-19 5 / 34
Application of the ICF on stuttering (Yaruss & Quesal, 2004) Mark Meersman. Lessius Antwerp: Symposium Stuttering. 2008, April 18-19 6 / 34
Biopsychosocial model implies a methodology of behaviour modification that apllies the principles of learning on communicative / stuttering behaviour by carefully selecting behaviour modification procedures by working with the client, the parents, the environment (peers, partners, teachers, colleagues...) Mark Meersman. Lessius Antwerp: Symposium Stuttering. 2008, April 18-19 7 / 34
Rationale > (at least) three factors... Predisposition genetics, brain (dys)function temperament? discoordination language/motor skills, linguistic fragility Precipitating (triggering) factors External stressors - fluency disruptors balance demands/ capacities? disharmonicity? emotional reactivity & regulation? Persisting factors "Reacting«learning! forming negative associations / connotations anticipation of trouble i.e., classical conditioning controlling by means of overt behavior i.e., operant conditioning vicarious learning coping with linguistic/social/emotional challenges Mark Meersman. Lessius Antwerp: Symposium Stuttering. 2008, April 18-19 8 / 34
On reacting to stuttering... I believe... believe... " (...) (...) That That most most children children who who begin begin to to stutter stutter become become fluent fluent perhaps perhaps because because of of maturation maturation or or because because they they do do not not react react to to their their lags, lags, repetitions, repetitions, or or prolongations prolongations by by struggle struggle or or avoidance. avoidance. That That those those who who do do struggle struggle or or avoid avoid because because of of frustration frustration or or penalties penalties will will probably probably continue continue to to stutter stutter all all the the rest rest of of their their lives lives no no matter matter what what kind kind of of therapy therapy they they receive. receive. That That these these struggle struggle and and avoidance avoidance behaviors behaviors are are learned learned and and can can be be modified modified and and unlearned unlearned though though the the lags lags cannot." cannot." Van Van Riper, Riper, Final Final Thoughts Thoughts about about Stuttering, Stuttering, J. J. Fluency Fluency Disord. Disord. 15 15 (1990), (1990), 317-318 317-318 Mark Meersman. Lessius Antwerp: Symposium Stuttering. 2008, April 18-19 9 / 34 9
On recovering from stuttering... "" we we must must stress stress that thatthe the recovery factor factor is is critical criticalin in evaluating young youngchildren who whohave have stuttered only onlya short short time. time. Once Oncea child childhas has stuttered for forseveral years, years, complete natural recovery is is somewhat unlikely. "" "" We We cannot cannothelp but butmake makethe the intruiging observation that thatcomplete recovery did didnot notoccur occurin in the the persistent children during duringthe the course courseof of the the study studyin in spite spiteof of intervention, whereas complete recovery occurred in in the the recovered group groupin in the the absence of of fluency fluencytreatment. "" (Yairi (Yairi & Ambrose, Ambrose, 2005, 2005, p. p. 194 194 & 190) 190) Mark Meersman. Lessius Antwerp: Symposium Stuttering. 2008, April 18-19 10 / 34
Rationale > Treatment goals Overt stuttering behaviour : Elimination of 'stutterlike disfluencies'?? Modification of 'stutterlike disfluencies': reduction of number, duration, tension Elimination of / minimal intensity and number of secondary behaviours More broadly: overt speech behaviour: linguistic, communicative, social and problem solving skills Cognitive and emotional reactions : Neutral, objective, realistic, problem-solving attitude about oneself as a speaker, speaking situations, the environment, Decreased sensitivity level / high(er) frustration tolerance, no anxiety, frustration, embarrassment, shame towards disfluencies, 'fluency disruptors', challenges in the real world (Bernstein-Ratner, april 2008) Increasing or maintaining good quality of life! Mark Meersman. Lessius Antwerp: Symposium Stuttering. 2008, April 18-19 11 / 34
Methodology Experimental design: clinical process as an equivalent of an experiment (empirical cycle)...with one subject (N=1) observation observation problem problem formulation formulation hypothesis hypothesis theory theory testing testing evaluation evaluation Mark Meersman. Lessius Antwerp: Symposium Stuttering. 2008, April 18-19 12 / 34
Methodology problem problem (intake) (intake) collecting collecting information information theory theory The clinical process as empirical cycle hypotheses hypotheses treatment treatment plan plan modification modification prodedures prodedures / / techniques techniques evaluation evaluation Mark Meersman. Lessius Antwerp: Symposium Stuttering. 2008, April 18-19 13 / 34
Methodology No cookery-book approach! DIAGNOSIS TREATMENT TREATMENT PLAN PLAN The empirical cycle in the cookery-book approach. (Hermans, Eelen & Orlemans, 2007) reduction of the empirical cycle to... making a diagnosis and executing a treatment that goes with it ' for each type of problem a "ready-made" treatment' ' an important limitation of this type of treatments is that, all too simplistic, they are placed in a one-to-one relation with descriptive diagnoses. One and the same problem won't always require one and the same treatment.' (Hermans, Eelen & Orlemans, 2007, p. 33) Mark Meersman. Lessius Antwerp: Symposium Stuttering. 2008, April 18-19 14 / 34
Methodology> flow chart 1 intake intake 2 establish establish relationship relationship collecting collecting information information 3 4 5 6 7 8 provisional provisional problem problem analysis analysis base base line line measurements measurements functional functional analysis analysis treatment treatment goals goals treatment treatment plan plan modification modification techniques techniques / / methods methods evaluation evaluation the behaviour therapeutic flow chart is not a set of do's and don'ts but a structure, based on the empirical cycle, that serves as a stencil for the clinical practice continue continue stop stop Mark Meersman. Lessius Antwerp: Symposium Stuttering. 2008, April 18-19 15 / 34
Methodology < cognitive behaviour therapy Methodology of (cognitive) behaviour therapy / experimental psychology... N=1 design Treatment = testing hypotheses about (elements of) the problematic behaviour treatment plan functional analysis: operants, coping analysis of dysfunctional/maladaptive emotions & attitudes meaning analysis evidence-based problem-oriented focusing on here and now action -oriented flexible individually tailored taking into consideration the importance of other factors e.g., therapeutic relationship Mark Meersman. Lessius Antwerp: Symposium Stuttering. 2008, April 18-19 16 / 34
Assessment setting up hypotheses Collecting data is one essential part of assessment... Reflecting on the relation between the collected data is even more important! for selecting treatment goals for selecting (covert and overt) behaviour modification procedures/methods/techniques This implies setting up hypotheses... based on the assessment results (testing, observation...), on knowledge (research findings) of phenomenology, etiology, cooccurence, etc. about causal, external and internal precipitating / aggravating and persisting factors about the development and persistence of specific covert and overt elements of the stuttering behaviour explanation of problematic character of the disorder in this particular client! E.g., avoidance, associated struggle behaviour... build up explanatory hypotheses together with client! "collaborative empiricism" Mark Meersman. Lessius Antwerp: Symposium Stuttering. 2008, April 18-19 17 / 34
1 intake intake 2 3 4 5 6 7 8 establish establish relationship relationship provisional provisional problem problem analysis analysis base base line line measurements measurements functional functional analysis analysis treatment treatment goals goals treatment treatment plan plan modification modification techniques techniques / / methods methods evaluation evaluation collecting collecting information information the behaviour therapeutic flow chart is not a set of do's and don'ts but a structure, based on the empirical cycle, that serves as a stencil for the clinical practice Mark Meersman. Lessius Antwerp: Symposium Stuttering. 2008, April 18-19 18 / 34
Example of development of a conditioned emotional response to a stuttering moment CS specific word or sound stuttering block UCS CR tension, shame UCR Mark Meersman. Lessius Antwerp: Symposium Stuttering. 2008, April 18-19 19 / 34
"Meaning Analysis" (MA) [ hypothesis concerning dysfunctional emotions & attitudes - classical cond. ] particular word CS expectation UCS/UCR UCR-representation block / irritation, tension anxiety CR psycho-physiology action tendencies: avoidance Mark Meersman. Lessius Antwerp: Symposium Stuttering. 2008, April 18-19 20 / 34
Example "Meaning Analysis" (MA) [ hypothesis concerning dysfunctional emotions & attitudes ] stuttering moment CS evaluation reference UCS/UCR UCR-representation make a fool of myself / tension, shame anxiety CR psycho-physiology action tendencies: avoidance Mark Meersman. Lessius Antwerp: Symposium Stuttering. 2008, April 18-19 21 / 34
Four pathways to anxiety (Rachman, 1977) personal experience modeling (vicarious learning) symbolic learning (e.g., being told...) imagination Mark Meersman. Lessius Antwerp: Symposium Stuttering. 2008, April 18-19 22 / 34
Functional Analysis (FA) [ hypothesis concerning dysfunctional (operant) overt behaviour - instrumental learning ] Context Sd : Operant behaviour R representation of positive behavioral consequences (Sr+) actual negative consequences (Sr-) «Someone does something (R) in a particular context Sd, because he expects Sr to happen, while in reality it leads to one or more negative consequences» Not necassarily consciously!! Mark Meersman. Lessius Antwerp: Symposium Stuttering. 2008, April 18-19 23 / 34
Example Functional Analysis (FA) [ hypothesis concerning dysfunctional (operant) overt behaviour - instrumental learning ] Sd : stuttering moment in situation with time pressure R : struggle Sr-representation of positive behavioral consequences: getting out of the block actual negative consequences: more tension, longer blocking Mark Meersman. Lessius Antwerp: Symposium Stuttering. 2008, April 18-19 24 / 34
Treatment selecting & implementing modification procedures Based on FA & MA! FA modifying overt behaviour e.g., block modification, modifying associated behaviours... MA decreasing negative emotions, cognitive restructuring... e.g., desensitization, cognitive training... Inspiration for realizing these procedures into concrete therapy activities : techniques and methods of different therapy programmes! Mark Meersman. Lessius Antwerp: Symposium Stuttering. 2008, April 18-19 25 / 34
1 intake intake 2 3 4 5 6 7 8 establish establish relationship relationship provisional provisional problem problem analysis analysis base base line line measurements measurements functional functional analysis analysis treatment treatment goals goals treatment treatment plan plan modification modification techniques techniques / / methods methods evaluation evaluation collecting collecting information information the behaviour therapeutic flow chart is not a set of do's and don'ts but a structure, based on the empirical cycle, that serves as a stencil for the clinical practice Mark Meersman. Lessius Antwerp: Symposium Stuttering. 2008, April 18-19 26 / 34
Modification procedures for modifying emotional responses MA exposure techniques - stopping rule - re-evaluate evaluate the UCS provid information / relabel counterconditioning CS sequential evaluative cognitive representations - omitt stimuli - add inhibitory stimuli - provide information / relabel - counterconditioning (syst. desens.) emotion Mark Meersman. Lessius Antwerp: Symposium Stuttering. 2008, April 18-19 27 / 34
exposure techniques - stopping rule - re-evaluate the UCS provide information / relabel / reality testing Example stuttering moment CS UCS/UCR UCR-representation make a fool of myself / tension, shame - adding inhibitory stimuli - providing information / relabeling - reality testing - counterconditioning (syst. desens.) anxiety CR psycho-physiology action tendencies: avoidance Mark Meersman. Lessius Antwerp: Symposium Stuttering. 2008, April 18-19 28 / 34
Modification procedures for modifying overt stuttering behaviour FA context: - omitting (avoiding) Sd - providing information about Sd - relabeling Sd behaviour - skills training (shaping, chaining ) - direct behavioural advice - modeling - exposure, time out, ignore: R consequence - for undesired behaviour: +S-, S+, -S+ - for desired behaviour: +S+, S-, -S- Mark Meersman. Lessius Antwerp: Symposium Stuttering. 2008, April 18-19 29 / 34
Some general features Good client-therapist relationship is crucial therapist as coach motivates, counsels/explains, structures, models Atmosphere of "collaborative empiricism" client / parents take an active part in identifying the precipitating and maintaining variables engagement! Strong focus on prevention of negative associations of negative 'action tendensies' Stepped-care start with least invasive & least time consuming interventions e.g., parent counseling if not sufficient: more extensive interventions e.g., direct intervention with the child + parent counseling Mark Meersman. Lessius Antwerp: Symposium Stuttering. 2008, April 18-19 30 / 34
General features > EBP Not protocol-like execution of ready-made interventions Nevertheless... EBP-attitude (Schacht & De Raedt, 2007): structure for collecting data in a systematized way formulation of hypotheses using scientifically validated tests and questionnaires, observation tools and checklists......and testing them by going through the empirical cycle hypotheses based on knowledge of evidence-based behavioural models treatment plan built hypotheses on relation between problem components wherever possible: application of evidence-based procedures (continuing) outcome assessment: validated tests and questionnaires + coninuously adjusting treatment Need for Practice-Based Evidence, representative for clinical situations... (Hafkenscheid, 2007) Mark Meersman. Lessius Antwerp: Symposium Stuttering. 2008, April 18-19 31 / 34
Conclusion Eclectic Social Cognitive Behavioural Stuttering Treatment : Heuristic model: provides a methodology for assessing and analyzing stuttering problems (formulate hypotheses), and for setting goals, and selecting and implementing modification procedures (testing hypothesis) in other words: not just WHAT & HOW, but mainly WHY & WHEN?! Integration of current knowledge and insights on phenomenology of stuttering & principles & applications of behaviour modification Strong focus on social-cognitive learning! Mark Meersman. Lessius Antwerp: Symposium Stuttering. 2008, April 18-19 32 / 34
Conclusion Eclectic Social Cognitive Behavioural Stuttering Treatment : Broad-based point of view on fluency problems (i.c. stuttering) and fluency treatment addressing overt features of the fluency problem and overall communication skills (or the lack of) addressing cognitive and emotional features of the fluency problem considering and/or addressing potential influence of temperamental features, parents sensitivity to the problem, coping skills etc. metatheoretical assumption: dynamic, biopsychosocial model Mark Meersman. Lessius Antwerp: Symposium Stuttering. 2008, April 18-19 33 / 34
Thank you! mark.meersman@lessius.eu Mark Meersman. Lessius Antwerp: Symposium Stuttering. 2008, April 18-19 34 / 34