Ego-States and Measures of Fluency: Unraveling Connections to Treatment

Outcome

William S. Rosenthal Department of Communicative Sciences and DisordersCalifornia State University, East Bay, Hayward, California

Shannon N. Austermann Hula San Diego State University / University of California, San

Diego Joint Doctoral Program in Language and Communicative Disorders, San Diego, California

Liz Rud Livermore Valley Joint Unified School District, Livermore, California

Unravel: (1)to separate or disentangle the threads of a fabric (2) to free from complications (3) to take apart, destroy

A recurrent thread in stuttering research--Is treatment success best

measured by: Counts of fluency breaks Changes in social and psychological

constructs such as: Increased speech output Increased social interaction Greater self acceptance

Previously, we

Discussed the theoretical relationship between life scripts, ego-states, and stuttering

Showed a change in ego-state over the course of successful stuttering therapy

Increase in function of ego states that exercise conscious control and support change

Decrease in ego state functions associated with resistance to change (Rosenthal, 2001)

Purpose of current study

Compare ego-state change and objective speech measures with an independent measure of treatment outcome

Estimate of the contribution of each of these constructs to treatment outcome.

Participants in the study

Thirty-two (32) young adult stutterers on active duty in the military (31 males, 1 female)

All participated in an 8-week intensive treatment program

Age range 18 to 35, mean 24 years

Treatment outcome ratings

Each participant was recorded (video and audio) at the beginning and end of treatment

The two-minute spontaneous speech samples were used in this analysis

Pre treatment and post treatment severity ratings used a 7 point equal appearing interval scale, from “Very Mild” to “Very Severe”

Participants were divided into two subgroups: High Success (N=21) and Low Success (N=11), following procedures described previously (Rosenthal, 2001)

Treatment outcome ratings (con’t)

The scale items were based on program goals (similar to Van Riper’s modification and SSMP)

Indications of excessive muscle tension while stuttering,

Indications of inefficiency, or undue delay in releasing tension,

Attempts to avoid or postpone stuttering, Inappropriate movements while stuttering that are

conspicuous and distracting, Instances of inappropriate rate associated with

stuttering, Instances of failure to initiate or maintain eye contact

with the camera while stuttering, and Instances of inappropriate loudness, pitch, or voice

quality associated with stuttering.

Ego State Analysis

Ego state strength was assessed from the visual record and from the content of transcripts of the pre- and post-therapy videos

Constructs, as defined by transactional analysis theory, were used (Berne, 1961)

Adult (A) Adapted Child (AC) Natural Child (NC) Nurturing Parent (NP) Critical Parent (CP)

Ego State Analysis (con’t)

Ego state ratings were based on non-verbal information only (following Dusay & Dusay, 1989)

Facial expressions Gestures Body posture

The relative strength of each ego state assigned a score that totaled 20 points for all ego states combined

Objective Measures

Adaptation of the Stuttering Severity Instrument (SSI) (Riley, 1980)

For the current study Stuttering Disfluency (SD) was defined as part

word repetitions, sound and syllable repetitions at the beginning of words, audible prolongations, inaudible blockages, and cessations of phonation.

A separate category of Indeterminate Disfluency (ID) was established. This category included whole word repetitions (mono and polysyllabic), phrase repetitions, interjections, extraneous words, filled pauses, and stereotyped starters.

Objective Measures (con’t)

Concomitant Behaviors (CB), included distracting sounds (noisy breathing, whistling, sniffing, blowing, or clicking sounds), facial grimaces (jaw jerking, tongue protruding, lip pressing, or jaw muscles tensing), head movements (moving back or forward, turning away, making poor eye contact, or constant looking around), and movement of extremities (arm and hand movement, hands about face, torso movement, leg movements, or foot tapping or swinging)

(Note: The total of all types of Concomitant Behaviors exhibited throughout the speech sample was recorded, rather than the rate per number of words, as was the case with all other measures)

In addition, Words Per Minute (WPM) and Total Words (TW) were counted for each of the two minute spontaneous speech samples

Ego State Changes

Previously discussed in detail in the preceding paper (Rosenthal, 2001)

Predictions were generally supported Successful treatment is associated with

increase in Adult Ego State and decrease in Adapted Child Ego State

Figure 1. Changes in Ego States for Low and High Treatment Success Groups (N=32)

-3

-2

-1

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1

2

Adult AdapChld

NatChld

NurtParent

CritParent

Ego States (See text for descriptions)

Dif

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Pre

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Th

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Low Success

High Success

Overall Change in Objective Measures

All measures moved in the expected direction by the end of treatment, four of the five significantly

Table 1. --Pre- and Post-Treatment Means of Various Objective Measures of Stuttering and Speech Rate: Words Per Minute, Total Words, Stuttering Disfluency (SD), Indeterminate Disfluency (ID), and Concomitant Behaviors (CB)

Change MeasuresWords/Min Total

WordsSD Change ID Change CB Change

Pre Rx Mean 94.02 187.5 10.79 12.7 3.77

SD 33.61 70.67 8.53 8.77 1.67

Post Rx Mean 110.17 219.4 8.29 5.93 2.16

SD 31.66 60.54 8.29 4.78 1.30

t= -2.649 -2.629 1.585 4.290 5.362

p .0126 .0132 .123 < .0002 < .0001

Statistically significant p values are shown in blue.

Changes Related to Treatment Outcome

Increased verbal output (Total Words) for High Success Group

Decreased disfluency (Stuttering Disfluency) for High Success Group

Table 2. Means, Standard Deviations, and Significance of Changes of Objective Measures of Stuttering andSpeech Rate: Words Per Minute, Total Words, Stuttering Disfluency (SD), Indeterminate Disfluency (ID),

and Concomitant Behaviors (CB) For High and Low Success Groups

Treatment Group

Words/Min Total Words SD Change ID Change CB Change

High Success M 23.6 49.7 -5.12 -8.36 -1.9

(N=21) SD 37.25 72.77 9.26 10.19 1.91

Low Success M 2.0 -2.0 2.50 -3.74 -1.05

(N-11) SD 24.03 46.08 5.78 4.92 1.06

t= -1.733 -2.134 2.479 1.736 1.379

p .0934 .0411 .019 .1035 .178

Statistically significant p values are shown in blue.

Addressing the core question: what measures predict treatment outcome?

We first looked at the relationship between objective measures and ego states

Moderate positive correlation between measures of verbal output and increased Adult Ego State

Moderate negative correlation between measures of verbal output and Adapted Child Ego State

Moderate to moderately-high positive correlations were found for all objective measures and the independent measure of treatment success

Previously showed treatment success is associated with high, pre-therapy ratings of Adapted Child (r = .48) and low loading of Adult (r = -.36)

Table 3. --Correlation (r) Between Ego States, Treatment Success and Various Objective Measures of Stuttering and Speech Rate: Words Per Minute, Total Words, Stuttering Disfluency (SD),

Indeterminate Disfluency (ID), and Concomitant Behaviors (CB)

Ego StatesWords/Min Total Words SD Change ID Change CB Change

Adult .354 .394 .179 .235 .315

Adapted Child -.396 -.435 -.121 -.030 -.232

Natural Child .084 .056 -.015 -.054 .186

Nurturing Parent .287 .299 .115 .101 .011

Critical Parent____ -.025______ 003_______ -.066______ .322________ -.185________

Treatment Success .587 .628 .506 .359 .379

Statistically significant r-values (p< .05) are shown in blue.

A Predictive Model

In the previous study (Rosenthal, 2001), we showed the predictive value of ego state change on treatment outcome. A step-wise linear multiple regression analysis was performed, with the dependent variable Treatment Success, and the independent variables the changes in Ego State Ratings from pre- to post-therapy. The variables of Adapted Child, Natural Child, and Nurturing Parent resulted in a multiple R of .57. The addition of the remaining variables did not significantly increase the predictability of treatment success.

A Predictive Model (con’t)

For the present study, we conducted a similar analysis to examine the predictive relationship of objective measures on treatment outcome. That analysis showed that the variables Total Words, Stuttering Disfluency, Indeterminate Disfluency, and Concomitant Behaviors resulted in a multiple R of .71, accounting for nearly 50% of the variance attributable to treatment outcome.

A Predictive Model (con’t)

Finally, we regressed all variables (ego state variables and objective variables) against treatment outcome. This resulted in a maximum R of .81 when all variables are accounted for. However, most of the variance in this model is due to a combination of all objective measures and a single ego state measure, Nurturing Parent. The corresponding multiple R is .79. The addition of the remaining ego state measures increases the predictive efficiency of the model by only 3.8%.

Table 4. --Stepwise Linear Multiple Regression with Treatment Outcome as the Dependent Variable with Steps 5 and 9 Shown.

INDEPENDENT VARIABLE

BETA Coefficient

Constant R F Ratio of R

STEP 5

Nurturing Parent .495168 .775765 .7986 8.6126

Total Words .00302

Stuttering Disfluency .039491

Indeterminate Disfluency .039695

Behavioral Concomitants .202075

STEP 9

Adult -.243372 .7184432 .8136 4.7868

Adapted Child -.332662

Natural Child -.273851

Nurturing Parent .205564

Critical Parent -.199486

Total Words .000498

Stuttering Disfluency .050201

Indeterminate Disfluency .039335

Behavioral Concomitants .209854

A Predictive Model (con’t)

Based on the regression models from the previous (Rosenthal, 2001) and current studies, we can summarize in the following way:

The use of Ego State change alone accounts for approximately 32% of treatment outcome variance

The use of Objective measures alone accounts for approximately 50% of treatment outcome variance

The combination of Ego State change and Objective measures accounts for approximately 66% of treatment outcome variance

A Predictive Model (con’t)

Objective measures emerge as the stronger predictor of treatment success, even in a treatment modality that does not emphasize fluency as a primary goal

Findings are limited to this study and this particular treatment approach. Similar studies on alternative treatment modalities are needed to flesh out these relationships.

Nevertheless, psychodynamic constructs, such as ego states, need to be included to complete the treatment model

The latter statement suggests a need for improved training in principles of counseling and psychotherapy for speech-language pathologists in general, and fluency specialists in particular.

ReferencesBerne, E. (1961) Transactional Analysis in Psychotherapy. New York: Grove Press

Breitenfeld, D.H. & Lorenz, D.R. (1989) Successful Stuttering Management Program for Adolescent and Adult Stutterers. School of Health Sciences, Eastern Washington University, Cheney, Washington.

De-Nil, L.F., Kroll, R.M., & Ham, R.E. (1996) Therapy review: Successful Stuttering Management Program (SSMP) Journal of Fluency Disorders, 21, 61-67.

Dusay, J.M.& Dusay, K.M. (1989) Transactional analysis. In Corsini, R.J. & Wedding, D. (Eds.) Current Psychotherapies (4th ed.) pp. 405-453. Itasca, IL: F.E. Peacock Publishers, Inc.

Naylor, R.V. and Rosenthal, W.S. (1968) Clinical Investigations of Stuttering: II. Treatment and Follow-up of the Adult Stutterer. Final Report, Project No. 3A-015601A826-01-036, U.S. Army Medical Research and Development Command, Washington, D.C.

Riley, G.D. (1980) Stuttering Severity Instrument for Children and Adults. Tigard, OR: C.C. Publications.

Rosenthal, W.S. (1997, August) Stuttering scripts: The transactional analysis of stuttering therapy. Paper presented at the Second World Congress on Fluency Disorders. San Francisco, CA.

Rosenthal, W.S. (1998) The transactional analysis of stuttering therapy: scripts and ego states. In E.C. Healy & H.F.M. Peters (Eds.) 2nd World Congress on Fluency Disorders Proceedings, San Francisco, California, 1997 (pp. 185-189). Nijmegen, The Netherlands: Nijmegen University Press.

Rosenthal, W.S. (2001) Relationship of change in ego-state to outcome of stuttering therapy: preliminary findings. In H-G. Bosshardt, J. S. Yaruss & H. F. M. Peters (Eds.) Fluency Disorders: Theory, Research, Treatment and Self-Help. Proceedings of the Third World Congress of Fluency Disorders in Nyborg, Denmark, 2000 (pp. 405-409). Nijmegen, The Netherlands: Nijmegen University Press.

Van Riper, Charles (1973) The Treatment of Stuttering. Englewood Cliffs, N.J.: Prentice Hall

Acknowledgements

This research was supported, in part, by an RCSA Faculty Grant from the California State University. Sandra Cullinan, Carol A. Murphy, and Vanna Sivilay Nicks served as raters for some of the data analyses cited in the present study, and that were reported in a preceding paper. Some of the data in this report were first presented at the Annual Convention of the American Speech-Language-Hearing Association, November 2001, New Orleans, LA

This has nothing to do with this paper. It is just my dog.

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