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A qualitative study of therapeutic effect from a user’s perspective
Journal of Fluency Disorders 29 (2004) 95–108
A qualitative study of therapeutic effect from a user’s perspective Trudy Stewart a,∗ , Gillian Richardson b a
Speech and Language Therapy Department, Leeds East PCT, St. James Hospital, Beckett Street, Leeds LS9 7TF, UK b Leeds United Hospitals Trust, Leeds, UK
Received 17 September 2001; received in revised form 11 October 2002; accepted 12 November 2003
Abstract This study investigated the experiences of adults who have completed a course of therapy for stammering. The objective was to inform clinicians about the effect of therapy by listening to the client’s own account of the experience after they had been discharged from therapy. The study involved individuals discussing their experiences and their views on the effect of therapy in an in-depth, semi-structured interview. The individual transcripts were subjected to analyses and several major themes emerged. A number of the themes had implications for clinical practice and these were considered in detail. The value of having a dialogue with clients about the effect of therapy after it has formally come to an end is discussed in relation to monitoring of therapeutic effectiveness. Educational objectives: The reader will be able to: (1) describe ways of evaluating the effect of therapy; (2) summarize qualitative methodology involving interviewing techniques; (3) utilize the client experience of therapy in monitoring therapeutic effectiveness. © 2004 Elsevier Inc. All rights reserved. Keywords: Stammering/Stuttering; User views; Therapy effect
From a therapeutic perspective, treatment effectiveness is the extent to which an intervention does what it is intended to do for a particular client or group of clients (Last, 1983). The measurement of effectiveness of any treatment involves both the study of the process and its outcome (Purser, 1987). Any profession wishing to maintain its clinical integrity will view treatment efficacy as a fundamental issue (Curlee, 1993). This issue of clinical effectiveness continues to be the subject of lively debate among those involved in the ∗
Corresponding author. Tel.: +44-133-206-4495. E-mail address: [email protected] (T. Stewart).
0094-730X/$ – see front matter © 2004 Elsevier Inc. All rights reserved. doi:10.1016/j.jfludis.2003.11.001
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treatment of those who stammer (Ingham & Bothe, 2001; Storch, 2001; Thomas & Howell, 2001). From a “purchasing” perspective, employing authorities are keen to ensure that any treatments compare favourably when measured against a “gold standard” of effectiveness and that resources are being deployed in the most efficient manner to achieve this outcome. Effectiveness of treatment is also a topic which commands the attention of researchers and clinicians as reflected in a number of recent publications (Thomas & Howell, 2001; Yaruss, Quesal, & Murphy, 2002a). 1. User perspective As Baer suggested in 1990, consumer groups are becoming actively involved in this debate and it is significant that their views and concerns appear to be driving some of the recent changes in clinical practice. For example, the need for early referral to specialist clinicians and the accessibility of certain treatment programmes for young children. The clinical audit of practice recommends user and carer involvement in evaluating treatments, and researchers are increasingly being encouraged to consider the views of clients. Such developments are contributing to bridging the gap between, on the one hand, judging effectiveness on purely empirical data and, on the other hand, evaluating what Storch (2001) describes as “clinically meaningful results about the real world benefits of treatment”. There have been several studies in the last few years, which have surveyed the opinions of consumer groups regarding treatment. Hayhow, Cray, and Enderby (2002) used a postal questionnaire to evaluate the views of people who stammer (PWS) in Britain about helpful or unhelpful therapeutic approaches, the value of alternative remedies and ideas regarding future developments of speech and language therapy. Analysis of the questionnaires revealed that no one treatment approach was identified as particularly helpful but respondents were generally satisfied with the therapy they had received. With regard to alternative remedies, hypnotherapy was the most popular but the benefits were regarded as poor. Comments on future developments generally fell into two categories: specific changes in therapy content and service delivery issues. A similar study was carried out by Yaruss et al. (2002b). They asked 200 members of the National Stuttering Association of America to comment on a variety of therapy issues, such as timing of referral for speech therapy, preferred setting to receive therapy, and “best goals” of therapy for children and adults who stammer. Results varied greatly across this particular population but there was general agreement that treatment should address both fluency and attitudinal change for children and adults. 2. Qualitative approaches To date most of the studies which concern themselves with evaluating effectiveness and outcomes of therapy through consideration of client or consumer views have been carried out “at arms length”. The mode of enquiry has largely been quantitative with studies investigating broad questions across large populations. The result of this is some knowledge of outcomes but no understanding of how this relates to individual client experiences in therapy or how clients make sense of those experiences once the process has ended.
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We believe there is now a place for evaluation of outcomes from the client’s perspective using qualitative methodologies. Other disciplines including education, sociology and social sciences, have acknowledged the strength of this approach and the subsequent rich information that it yields. For example, in the field of psychology, Mair (1989) argued that “personal knowledge” is likely to be more informative than “distant knowledge”. Mair asks therapists to reconsider the necessity of looking with “detachment” and “separateness” and suggests our primary attention should be given to the person in the context of their life situation, trying to understand by “living in our experience of ourselves and others”. This view has been reflected in the dysfluency literature by Quesal (1989) among others. Corcoran and Stewart (1998) also argue that recent trends in stammering research have led us away from consideration of the personal knowledge of our clients: “As a result of the predominance of the quantitative paradigm of research within speech-language pathology, a significant portion of the reality of what it is to be a person who stutters has been excluded from investigation”. One of the key features of qualitative research is the focus on how people understand and derive meaning from their worlds. This information is usually expressed verbally and relates to processes as well as feelings and emotions. As a result the data collection is a social interaction between the researcher and the research participant in order to evaluate a particular process. “Qualitative researchers talk with people about their experiences and perceptions” (Pattern & Westby, 1992). Tetnowski and Damico (2001) demonstrated the advantages of qualitative methodologies in research into stammering. They listed the following implications of qualitative approaches (pp. 34–35): • researchers will be able to collect authentic data that are true representations of how stuttering impacts on individuals in the real world . . . • researchers will be able to create a richer description of what stuttering is, focusing on actual behaviours, strategies, and resources employed by the PWS before, during and after moments of stuttering . . . • researchers will be able to focus on the impact of stuttering on individuals and you will be able to collect data from the perspective of the individual person who stutters . . . • researchers will be able to focus on the PWS and their collaborations with their coparticipants within the social context . . . • researchers will learn more about the phenomenon under investigation, how it operates, and how PWS attempt to reduce its impact in social contexts However, the value of a qualitative approach applied to evaluating therapeutic effect from a client’s perspective was not included in their list. A similar omission was made by Mowrer (1998) when writing on the relative benefits of various methodologies. Interestingly, he discussed the importance of parental reports in the context of childhood dysfluency but did not make any mention of client self-reporting in either the treatment of adolescents/adults who stammer or evaluating the effect of therapy. This knowledge of the personal has important ramifications for evaluating clinical practice for researchers and especially clinicians. The benefits of applying qualitative methodologies
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to client-based evaluations can be listed as following: • the collection of rich data on client reflections of the therapeutic process • comparative studies comparing client and clinicians views on how therapeutic aims/ objectives have been achieved • consideration of what part of the process of intervention is perceived by the client as affecting and/or not affecting change • the evaluation of the long term effects of therapy Thus, tending and attending to what the client has to say about his experiences, his stammer, his therapy can be enlightening and arguably of greater value to the clinician. This is especially important when both are engaged in the same therapeutic process, when experiences and perceptions can be validated and/or invalidated. This study was an attempt to engage in such a process. The aim was to gather rich data based on “personal knowledge” by asking adults who had been involved in speech and language therapy to talk about their experiences of therapy, to listen and learn from their stories, and to reflect on the effects of the intervention from their point of view. Comparisons were to be drawn between the clinician’s perceived outcomes and how these related to the clients’ own experiences, including the longer-term effects of therapy. Attempts were also to be made to identify the key features of the process that contributed to positive change in individuals.
3. Methodology 3.1. Qualitative methodology While there are several different qualitative approaches that could have been applied to this study, it was important to select a methodology that fulfilled the aims. A phenomenological approach was chosen using in-depth, semi-structured interviews carried out with a small number of individuals. Crabtree and Miller (1991) described the data generated from this type of interview as “taped stories derived from informants through several broad, open-ended questions and follow-up prompts”. A topic guide to the interview was developed, firstly by identifying important questions for consideration, then grouping these into a coherent format and finally ordering these questions in a logical way. A pilot interview was carried out using the topic guide with one male client who had attended individual and group therapy sessions from the identified service and was no longer attending therapy. The topic guide was as follows: 1. Speech — opening question: “Tell me about your speech now”. Follow-up questions were: • Level of fluency at present • Concern about stammer • Control of stammer • Ability to manage communication issues/situations which may arise in the future
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2. Speech and language therapy — opening question: “Tell me about the therapy you attended”. Follow-up questions on therapy were: • • • • • • •
Speech Ability to control speech Feelings and emotions Life style, perspectives on life and employment issues Isolation Support Self-esteem, confidence
3. The degree to which speech and language therapy fulfilled the individual’s expectations — opening question: “In what way were your initial expectations of therapy met or not met?” 4. Interactions with the speech and language therapist — opening question: “What aspects of your interaction with the therapist/s did you find most/least helpful?” 3.2. Client participants Clients were selected on the basis of being “experiential experts” in this instance, experts in the experience of a particular therapeutic intervention within a particular time frame (i.e., intensity sampling). Invitations to participate in the study were sent to 77 clients involved in group therapy, facilitated by the same two therapists, and who had been discharged from therapy between 1995 and 1999. Invitations were posted to clients’ home addresses on the basis of information held on case records at the time of discharge. Additional invitations were sent to members of the local self help group who had also had therapy and been discharged during the same period. A total of 13 clients volunteered to take part in the study. Three people failed to attend for interview. Ten people were interviewed but two did not meet the criteria for inclusion in the study. One male had not had therapy in the agreed location and a second male had therapy principally for a neurological condition. Eight client interviews formed the basis of this study. While the sample was small, the clients who took part represented a diverse group. The age range was 23–59 years, mean 41.5 years and there were a range of occupations represented (i.e., student, cabinet maker, project engineer, graphic designer, accountant, chef). Seven were male, and one was female and all had therapy within the same programme, individually with one of two specialists in dysfluency and in a group therapy setting in which the therapists worked together. Therapy comprised a combination of “speak more fluently” and “stammer more fluently” approaches and was grounded in client-centred and personal construct psychological theories and therapy. Within the therapy process clients selected techniques which were appropriate to their individual needs and stammering symptoms. Each individual experimented with using a variety of techniques in group and individual clinic settings and in their wider social interactions. Of those who volunteered to take part in the study, no individual was currently in therapy; one had been discharged in 1996 and the remainder between 1998 and 1999.
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3.3. Interviews The interviews were based on the topic guide described above, with the interviewer asking open-ended questions with some follow-up questions. However, it was made clear in the interview that other relevant issues could also be raised as necessary. The interviews were scheduled to last for one and a half hours and every effort was made by the interviewer to facilitate an open and relaxed atmosphere within the interview, to enable the adults to raise any issues they considered important to their experiences. The interviewer was not known to the clients and had not been involved in any stage of the therapy process. Six interviews took place in a “neutral” environment, i.e., a meeting room in the administrative headquarters of a local hospital, which had no connection with the location of clients’ therapy. Two interviews were held in the clients’ home, as this was more convenient for them. The interviews were taped in their entirety using a Marantz stereo cassette recorder (model CP 230) with stereo microphone (Marantz EM-8). Permission was obtained from each client to tape record the interviews prior to recording and the equipment was placed to optimise recording quality in each setting. 3.4. Analysis An independent assistant transcribed the taped narrative elicited in each interview and this transcription was then verified by the interviewer. These anonymous transcripts comprised the data used in this study. The data was subjected to qualitative analysis (Cresswell, 1998; Miles & Huberman, 1994; Moustakas, 1994). The analysis consisted of three sequential and linked processes: 1. Data reduction — in which the primary researcher and the interviewer independently summarised, coded and broke down the transcripts into themes. Notes were made at this juncture regarding the possible significance of each of the client’s response. For example, “I had a period in London when I went to the City Lit. for a year or so to a regular evening group session, because I felt in need of support at the time” was noted as “previous therapy”. (“City Lit.” is the City Literary Institute in London, which is an educational establishment responsible for running a number of adult courses including several for adults who stammer.) Some responses were allocated more than one notation, for example, “I get the feeling my fluency is better now than it was before going into therapy with T. (therapist) and the group sessions that we had” was noted as “current status of speech” and “outcomes of therapy”. 2. Data display — in which the data was organised by the researchers. In this process each researcher identified recurring themes firstly for each client and then across different clients. Not all themes were generated by all clients but it was felt to be important to note all topics at this stage. 3. Conclusion drawing and verification — in this process the independent findings of the two investigators were compared. The notations made against responses were discussed. It was observed that although the analysis had been carried out independently, there were few areas of disagreement. The researchers then discussed and agreed upon the recurring
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themes in the data. While the same major themes were identified, the names and exact content or grouping of responses under given themes required some consideration. For example, clients discussed their level of concern regarding their speech and there was a discussion as to whether or not this needed to be a separate issue or could be included in “current status”. It was agreed that the more overt features (i.e., stammering behaviours) should be included under current status and covert or psychological issues be separated under another theme, representing the emotional aspect of stammering. The first author carried out a second review of the agreed themes in relation to individual client responses. Finally, in addition to the methodological procedures outlined above, further validation of the data was carried out. To counteract possible researcher bias, the data was subjected to analysis by an independent speech and language therapist with no previous contact with the clients or involvement in the therapeutic process under review. She reviewed the transcripts and the themes that had been assigned to the responses and outlined areas, which required clarification or modification. Following her comments the data was reviewed and appropriate changes made to the categorisation of responses in relation to identified themes. Once this process had been completed the transcripts were coded according to the agreed themes and Non-numerical Unstructured Data by Indexing Searching and Theorising (NUD*IST) was used to store the transcripts electronically. NUD*IST is a leading software programme, designed by Lynne Johnson at the University of Gloucestershire in England and well established in qualitative data analysis.
4. Results A number of themes were identified using the analysis detailed above. Some issues were mentioned by only one or two individuals and these were not included in the general consideration. Themes that recurred in the interviews of all the individuals were categorised and defined as follows: 1. Current status of communication — the client’s description and evaluation of the overt features of their speech and the effect these had on their social interaction at the time of interview. 2. Covert features of stammering — the client’s description of their current experience of the less overt symptoms of stammering, for example, avoidance behaviours, anxiety related to speaking, their degree of concern about their speech. 3. Coping strategies — the client’s report of any specific management techniques used to control and/or reduce overt and covert stammering symptoms. 4. Details of content or stages of therapy process — the client’s description of their experience of the group therapy programme, including specific details of exercises, group interactions, etc. 5. Comments on speech and language therapists involved in therapy — any reference made to interactions with the therapists running the group therapy programme, including comments on therapeutic style, specific behaviours (i.e., supportive, challenging, empathetic).
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6. Support issues — comments made by clients regarding any networks of support they had experienced and the nature of the help received from others. 7. Immediate effects of therapy — those reported changes which occurred both during the group therapy programme and in the short term follow-up/review period (i.e., up to 1 month after the group). 8. Long term outcomes of therapy — changes which were sustained following discharge from therapy (i.e., reported 1 year after the group). 9. Suggestions on how the therapy programme/approach might be modified — ideas offered by individual clients regarding change to any aspect of the group therapy (e.g., timing, location, organisation, therapeutic approach, therapist style, specific exercises included in the programme). In consideration of the effect of therapy, some of these themes were considered more pertinent than others (e.g., items 7–9). These specific items were analysed in detail and reference will be made to quotations from individual transcripts in discussion of these issues in the following section. 4.1. Effects of therapy • Reduced isolation: The opportunity afforded by group therapy to meet and discuss with like-minded people was greatly valued. Of the individuals interviewed three had not had this chance previously and found it very beneficial. The effect of group therapy in reducing a sense of isolation appeared to have a lasting effect and two individuals perceived this issue to be a turning point in the therapeutic process. “I walked in, a big circle of people sitting around — a bit nerve racking to say the least. I’d never been in a situation like that before. It was really like the conversion on the road to Damascus. It was absolutely wonderful, instant light going on over my head. It was wonderful to meet other stammerers, wonderful to share experiences. From that day on it just improved”. (Mr. H) • Support: Three individuals talked positively about the contact they had with other adults who stammer. They reported a sense of loss when individuals left the group at the end of their therapy and, in some instances, discussed continuing friendships with ex-group members. “The supporting nature of the speech therapy and self help group is beyond price. To be able to support and empathetic understanding is essential. To be able to speak from direct experience is crucial. Speech therapy gave me some wonderful friends, friends who are caring and concerned and appreciate from the first hand experience exactly what it is like to live and cope with a stammer”. (Mr. A) • Improvements made in the group: seven of the eight interviewees reported on significant changes they had experienced while attending the group therapy sessions. For some this experience was “dramatic”; two individuals reported not experiencing change until they joined the group.
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“I had quite a lot of individual therapy but it was not half as effective as a group therapy. As soon as I moved into the group therapy my confidence and self esteem just went up like a rocket”. (Mr. A) For others change appeared to be linked with feelings of being at ease within a communication setting. “Towards the end I felt very comfortable. I could do anything in the group that was asked. I was fluent in the group. I felt so comfortable that I was fluent”. (Mrs. A) • Increased fluency: Most individuals (i.e., seven out of eight) perceived themselves as generally more fluent. The interviewees talked of their feelings of greater speech control in different situations as a result of therapy. There was a lack of general agreement on which techniques were helpful and people’s experiences were very different. For example, relaxation, rate control, desensitisation, focusing on the content of utterances were all described by different people as helpful. Two people thought block modification and voluntary stammering were unhelpful. • Transfer issues: It was clear that some of the group experiences did not appear to generalise to situations outside the group. There were a number of comments made on the “artificial” nature of the group. “In the group I felt confident there. Yes, it was enjoyable but it is totally different outside. It was a bit artificial”. (Mr. F) The group therapy sessions were experienced as a stark contrast with the outside world and consequently made the application of skills learnt or suggested by the group difficult to use in everyday situations and this continued after therapy had ended. There was not a sense that skills were built upon and situations became easier with time. • Maintenance strategies: A focal aspect of the group therapy sessions was the establishment of a tailor made set of strategies or “toolbox” with which each client left the group. Half of the interviewees discussed the usefulness of these strategies. One person, while able to recall specific fluency controlling techniques, could not remember his maintenance “tools”. Another individual discussed the static nature of his strategies. “I’m not convinced that speech therapy gives you the ability to continue to control your speech because if that was the case my speech should just keep on improving. It should be better than it was 4 years ago, but its not”. (Mr. E) • Long term effects: While individuals continued to experience variability in speech control, for many fluency was less of an issue of concern. “. . . it was the desensitisation that seemed to take over, and so I said to myself, “what the hell, I’m a stammerer, so what?” And I tried it and it worked. I got confidence and a lot more outgoing and I wasn’t afraid of half the things I was before I went to speech therapy. Anyway it’s just gone on from there”. (Mr. G) • Changes in attitude: Comments indicated changes both in general terms and in relation to specific situations which had previously been problematic. Individuals discussed a number of changes in relation to particular speaking situations, for example, telephoning.
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Seven clients reported significant changes in what they felt able to do. Five talked in detail about feeling less fearful in specific situations and how events generally had less impact on their ability to see themselves in a positive light. “Not much crushes me now like it used to”. (Mr. H) • Changes in life style: Not all of those interviewed felt that their experiences of therapy had affected their life style. However, half of the interviewees discussed significant changes in training and employment opportunities, and social activities. “I think that speech therapy has given me the confidence to do what I have done in terms of my employment. Going back to University, qualifications, starting work, changing jobs. So yes my speech therapy has had effects on that”. (Mr. E) “. . . going to the Himalayas. Quite a large amount of social activity is connected to that. Quite confident about that and I am really looking forward to going away. I put that down solidly as a result of going to speech therapy and it being successful”. (Mr. H) • Suggestions on how the therapy programme/approach might be modified: incorporation of other techniques into the programme: One individual criticised the programme for not incorporating the ideas of a specific independent practitioner. “So if some people like this diaphragm thing they get the benefit out of it and if some people don’t like it its good to think about it and introduce it. So it would be good to give them a handout, you know, if you are interested do this at home. Don’t just say no it won’t work. We are not interested. Anything that would help someone to regain their fluency should be considered, it’s important to us”. (Mr. C) • Counselling: It was interesting to note the difference of opinion regarding the balance of counselling and skill based therapy carried out within the group. As previously stated the therapy was grounded in client-centred and personal construct psychology. The therapists themselves had postgraduate training in a variety of psychological approaches and in particular one of the therapists was a trained counsellor. One client in particular stated that there was not enough emphasis placed on the psychological impact of stammering within therapy and went on to discuss the role of the speech and language therapist and counselling. • Generalisation/transfer of skills: This was of concern to three of the interviewees. In particular, time allocated to work on interview skills and techniques, speaking on the telephone and regular group presentations were suggested. • Additional support: Those who were interviewed made several suggestions about the nature of sessions that could be offered after group therapy. These included booster sessions/weekends, periodic, compulsory follow-up appointments, and advanced group sessions or day courses. “Exactly, for people who have actually finished. Like a day’s course, a weekend course for people who have actually completed the course. I don’t know what extra I’m looking for. It’s just that bit more. Not just fluency in my speech but fluency in my overall presentation”. (Mr. E)
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5. Discussion and conclusions There are a number of considerations regarding the client sample and the methodology. Firstly as this was a qualitative study, an exploration of individual experiences of therapy, there will be no attempt to suggest these findings are generalisable and typical of all people who stammer. While the small sample is not an issue in such an in-depth qualitative approach, the selection of the clients needs to be discussed. While every attempt was made to involve a wide range of “experiential experts”, the final group of interviewees contained a proportion of individuals who had some association with the local self help group; two were members of the group at the time of the interviews and two had been involved in the past but were not currently attending group meetings. This may have had a bearing on some of the responses made by these individuals. For example, the fact that they had some association with the self help group could be interpreted as their personal need for ongoing support which was crucial to how they managed their stammering. Thus, these individuals may have used a similar construction process in their understanding of the meaning of therapy for them (i.e., on the continuum “provides support — does not provide support”). While the individuality of the data is more important that any generalisations, it is interesting to note that these types of responses may be more typical of those clients who go on to membership of self help groups after therapy has ended. The interviews yielded detailed, personal information from those who were interviewed. It should be noted that only a small proportion of the total sample from the interviews has been discussed in this paper. The data considered here did, however, highlight a number of pertinent issues in relation to the effect of the therapeutic process. Firstly, it threw light on the importance adults who stammer place on meeting with each other and sharing experiences, without necessarily needing input from a third party. There seemed to be a lasting positive effect on individuals’ self-esteem and self-perception when they become aware that others share similar difficulties and they are not alone. The reduction in isolation effect has been noted in other therapeutic groups. For example, Yalom (1995) in his discussion of group psychotherapy talks about clients having a “heightened sense of uniqueness” which becomes invalidated in the therapy process. In the therapy group, especially in the early stages, the disconfirmation of a patient’s feelings of uniqueness is a powerful source of relief. After hearing other members disclose concerns similar to their own, patients report feeling more in touch with the world and describe the process as a “welcome to the human race” experience. (p. 6) The significance of this sharing of experiences within a group setting may often be missed by therapist bent on teaching specific fluency skills or adhering to a set programme of activities. Although the clinicians involved were aware of the function of the therapy groups in reducing isolation, the information from these interviews underlined the importance of this. As a result changes were made in the format of group sessions to maximise exchange of information and establish group support networks (e.g., telephone link schemes). Benefits of group sessions were attributed to different aspects of therapy and there did not seem to be any “universal truths” about the use of specific techniques to enhance fluency or change particular attitudes. This seems to point to the need for therapists and clients to jointly experiment with a variety of approaches and design a number of strategies appropriate for
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each individual. Following reflection by the clinicians this issue has also been incorporated more fully into group therapy sessions. The adults who talked of long term benefits of therapy included speech change, reduced anxiety in certain situations and a general “enabling”; a feeling of not being held back by speech difficulties. Of particular concern was the way some individuals felt therapy had not helped them to continue the process of change. While the clinicians were aware of the difficulties in transferring skills from a clinical setting and maintaining them in the client’s natural environment and had designed therapy around naturalistic social settings this was obviously not enough. Reflections on the interviewees comments have lead to the further development of the group therapy programme. There is now more of an emphasis on the dynamic nature of “tools” in an individual’s “toolbox”; tools that will evolve to meet the person’s changing requirements and the demands which might be placed upon him/her in the future. This approach recognises a person as constantly learning, developing and “reinventing” him or herself. Any intervention that has at its core long-term change needs to ensure the desired outcomes are also dynamic in nature. Finally, the interviewees talked a great deal about the need for ongoing support. It was not clear whether or not the inadequacy of their maintenance strategies had compounded this need or if there were other factors involved. This issue of support will continue to be reviewed with clients on discharged and at subsequent review meetings requested by clients. It does, however, raise the question of timing of discharge of adults who stammer. This study seems to suggest the need for a more flexible, open-ended approach to discharge, which is not easy to achieve within the current models of service delivery where purchasers require information on exact numbers of contacts/clinical sessions in order to agree a cost of intervention. It is interesting to compare these results with other studies that describe therapeutic factors rated as most helpful by clients in, for example, psychotherapy groups. There is considerable agreement with the most commonly chosen factors being: • • • • •
catharsis (i.e., the expression of feelings) self-understanding (i.e., discovering and accepting aspects of self previously unknown) interpersonal input (i.e., receiving feedback from others on how the self is portrayed) cohesiveness (i.e., reduced isolation) and universality (i.e., learning that other people share the same problem and concerns) (Yalom, 1995).
Aside from the specific issues that have arisen out of the data, this paper also highlights other points with regard to clinical effectiveness. The need for evaluation of effect and effectiveness of any therapeutic programme is clear. However, what form this should take has been the subject of much debate. In discussing the gap between scientific investigation and clinical practice Guitar (1999) argues for a research “attitude” in clinic. “We urge that all clinicians use the scientific method in assessing and improving their practice to help us grow as a profession”. This study has demonstrated one way in which clinicians might be informed of the effect and the effectiveness of the practice in which they are engaged but has highlighted the significance of involving clients in this evaluative process. The validity of the outcomes of the specific intervention under review has been given added weight because clients have been able to discuss their personal
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experiences of it. One might argue that the most important “gold standard” of effectiveness is one where the client perceives the outcome as of value. CONTINUING EDUCATION A qualitative study of therapeutic effect from a user’s perspective QUESTIONS 1. This study is a consideration of therapeutic effect: a. from reflections by the therapist b. by comparing therapist and client reports c. from the client’s perspective d. from objective speech measures e. from an analysis of therapeutic dynamics 2. This study used a qualitative methodology involving: a. structured interviews b. in-depth interviews c. questionnaires d. focus groups e. narrative based accounts from clients 3. Thematic analysis of the data revealed: a. therapy reduced feelings of isolation b. therapy successfully incorporated a range of ideas from various sources c. therapy promoted long term fluency gains d. therapy mirrored real life situations e. most clients continued to have negative speech attitudes 4. Results suggested some specific changes to the therapeutic programme: a. clients required a more dynamic set of maintenance tools b. clients required a more comprehensive set of therapeutic tools c. clients required greater knowledge and use of fluency skills d. clients needed stronger support networks e. clients require regular review appointments 5. The study advocates some changes to client management on discharge: a. therapists to review clients following discharge b. therapists to send letters to clients inviting them to comment on their therapy c. reflective notes to be written by the therapist(s) d. therapist to have an open ended discharge policy e. clients to set up support networks
References Baer, D. M. (1990). The critical issue in treatment efficacy studies is knowing why treatment was applied. In L. B. Olswang, C. K. Thompson, S. F. Warren, & N. J. Minghetti (Eds.), Treatment efficacy research in communication disorders. Rockville, MD.
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Corcoran, J. A., & Stewart, M. (1998). Stories of stuttering: A qualitative analysis of interview narratives. Journal of Fluency Disorders, 23(4), 247–264. Crabtree, B. J., & Miller, W. L. (1991). A qualitative approach to primary care research: The long interview. Family Medicine, 23(2), 145–151. Cresswell, J. W. (1998). Qualitative inquiry and research design. Thousand Oaks, CA: Sage. Curlee, R. F. (1993). Evaluating treatment efficacy for adults: Assessment of stuttering disability. Journal of Fluency Disorders, 18, 319–331. Guitar, B. (1999). Bridging the gap between the science and clinical practice. In N. Berstein-Ratner & E. C. Healey (Eds.), Stuttering research and practice. London: Lawrence Erlbaum Associates Publishers. Hayhow, R., Cray, A. M., & Enderby, P. (2002). Stammering and therapy views of people who stammer. Journal of Fluency Disorders, 27(1), 1–17. Ingham, R. J., & Bothe, A. K. (2001). Thomas and Howell (2001): Yet another “exercise in mega-silliness”? Journal of Fluency Disorders, 27, 169–174. Last, J. M. (1983). A dictionary of epidemiology. New York: Oxford University Press. Mair, M. (1989). Between psychology and psychotherapy: A poetics of experience. London: Routledge. Miles, M. B., Huberman, A. H. (1994). Qualitative data analysis. Thousand Oaks, CA: Sage. Moustakas, C. (1994). Phenomenological research methods. Thousand Oaks, CA: Sage. Mowrer, D. E. (1998). Alternative research strategies for the investigation of stuttering. Journal of Fluency Disorders, 23(2), 89–97. Pattern, M., & Westby, C. (1992). Ethnography and research: A qualitative view. Topics in Language Disorders, 12(3), 1–14. Purser, H. (1987). The psychology of treatment evaluation studies. In L. Rustin, H. Purser, & D. Rowley (Eds.), Progress in the treatment of fluency disorders. London: Taylor & Francis. Quesal, R. W. (1989). Stuttering research: Have we forgotten the stutterer? Journal of Fluency Disorders, 14, 153–164. Storch, E. A. (2001). Incorporating effectiveness research in assessing the validity of stuttering treatment. Journal of Fluency Disorders, 27, 175–176. Tetnowski, J. A., & Damico, J. S. (2001). A demonstration of the advantages of qualitative methodologies in stuttering research. Journal of Fluency Disorders, 26(1), 17–42. Thomas, C., & Howell, P. (2001). Assessing efficacy of stuttering treatments. Journal of Fluency Disorders, 26, 311–333. Yalom, I. D. (1995). The theory and practice of group psychotherapy. New York: Basic Books. Yaruss, J. S., Quesal, R. W., & Murphy, B. (2002a). National Stuttering Association members’ opinions about stuttering treatment. Journal of Fluency Disorders, 27(3), 227–242. Yaruss, J. S., Quesal, R. W., Reeves, L., Molt, L. F., Kluetz, B., Caruso, A. J., et al. (2002b). Speech treatment and support group experiences of people who participate in the National Stuttering Association. Journal of Fluency Disorders, 27(2), 115–134.
A qualitative study of therapeutic effect from a user’s perspective Trudy Stewart a,∗ , Gillian Richardson b a
Speech and Language Therapy Department, Leeds East PCT, St. James Hospital, Beckett Street, Leeds LS9 7TF, UK b Leeds United Hospitals Trust, Leeds, UK
Received 17 September 2001; received in revised form 11 October 2002; accepted 12 November 2003
Abstract This study investigated the experiences of adults who have completed a course of therapy for stammering. The objective was to inform clinicians about the effect of therapy by listening to the client’s own account of the experience after they had been discharged from therapy. The study involved individuals discussing their experiences and their views on the effect of therapy in an in-depth, semi-structured interview. The individual transcripts were subjected to analyses and several major themes emerged. A number of the themes had implications for clinical practice and these were considered in detail. The value of having a dialogue with clients about the effect of therapy after it has formally come to an end is discussed in relation to monitoring of therapeutic effectiveness. Educational objectives: The reader will be able to: (1) describe ways of evaluating the effect of therapy; (2) summarize qualitative methodology involving interviewing techniques; (3) utilize the client experience of therapy in monitoring therapeutic effectiveness. © 2004 Elsevier Inc. All rights reserved. Keywords: Stammering/Stuttering; User views; Therapy effect
From a therapeutic perspective, treatment effectiveness is the extent to which an intervention does what it is intended to do for a particular client or group of clients (Last, 1983). The measurement of effectiveness of any treatment involves both the study of the process and its outcome (Purser, 1987). Any profession wishing to maintain its clinical integrity will view treatment efficacy as a fundamental issue (Curlee, 1993). This issue of clinical effectiveness continues to be the subject of lively debate among those involved in the ∗
Corresponding author. Tel.: +44-133-206-4495. E-mail address: [email protected] (T. Stewart).
0094-730X/$ – see front matter © 2004 Elsevier Inc. All rights reserved. doi:10.1016/j.jfludis.2003.11.001
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treatment of those who stammer (Ingham & Bothe, 2001; Storch, 2001; Thomas & Howell, 2001). From a “purchasing” perspective, employing authorities are keen to ensure that any treatments compare favourably when measured against a “gold standard” of effectiveness and that resources are being deployed in the most efficient manner to achieve this outcome. Effectiveness of treatment is also a topic which commands the attention of researchers and clinicians as reflected in a number of recent publications (Thomas & Howell, 2001; Yaruss, Quesal, & Murphy, 2002a). 1. User perspective As Baer suggested in 1990, consumer groups are becoming actively involved in this debate and it is significant that their views and concerns appear to be driving some of the recent changes in clinical practice. For example, the need for early referral to specialist clinicians and the accessibility of certain treatment programmes for young children. The clinical audit of practice recommends user and carer involvement in evaluating treatments, and researchers are increasingly being encouraged to consider the views of clients. Such developments are contributing to bridging the gap between, on the one hand, judging effectiveness on purely empirical data and, on the other hand, evaluating what Storch (2001) describes as “clinically meaningful results about the real world benefits of treatment”. There have been several studies in the last few years, which have surveyed the opinions of consumer groups regarding treatment. Hayhow, Cray, and Enderby (2002) used a postal questionnaire to evaluate the views of people who stammer (PWS) in Britain about helpful or unhelpful therapeutic approaches, the value of alternative remedies and ideas regarding future developments of speech and language therapy. Analysis of the questionnaires revealed that no one treatment approach was identified as particularly helpful but respondents were generally satisfied with the therapy they had received. With regard to alternative remedies, hypnotherapy was the most popular but the benefits were regarded as poor. Comments on future developments generally fell into two categories: specific changes in therapy content and service delivery issues. A similar study was carried out by Yaruss et al. (2002b). They asked 200 members of the National Stuttering Association of America to comment on a variety of therapy issues, such as timing of referral for speech therapy, preferred setting to receive therapy, and “best goals” of therapy for children and adults who stammer. Results varied greatly across this particular population but there was general agreement that treatment should address both fluency and attitudinal change for children and adults. 2. Qualitative approaches To date most of the studies which concern themselves with evaluating effectiveness and outcomes of therapy through consideration of client or consumer views have been carried out “at arms length”. The mode of enquiry has largely been quantitative with studies investigating broad questions across large populations. The result of this is some knowledge of outcomes but no understanding of how this relates to individual client experiences in therapy or how clients make sense of those experiences once the process has ended.
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We believe there is now a place for evaluation of outcomes from the client’s perspective using qualitative methodologies. Other disciplines including education, sociology and social sciences, have acknowledged the strength of this approach and the subsequent rich information that it yields. For example, in the field of psychology, Mair (1989) argued that “personal knowledge” is likely to be more informative than “distant knowledge”. Mair asks therapists to reconsider the necessity of looking with “detachment” and “separateness” and suggests our primary attention should be given to the person in the context of their life situation, trying to understand by “living in our experience of ourselves and others”. This view has been reflected in the dysfluency literature by Quesal (1989) among others. Corcoran and Stewart (1998) also argue that recent trends in stammering research have led us away from consideration of the personal knowledge of our clients: “As a result of the predominance of the quantitative paradigm of research within speech-language pathology, a significant portion of the reality of what it is to be a person who stutters has been excluded from investigation”. One of the key features of qualitative research is the focus on how people understand and derive meaning from their worlds. This information is usually expressed verbally and relates to processes as well as feelings and emotions. As a result the data collection is a social interaction between the researcher and the research participant in order to evaluate a particular process. “Qualitative researchers talk with people about their experiences and perceptions” (Pattern & Westby, 1992). Tetnowski and Damico (2001) demonstrated the advantages of qualitative methodologies in research into stammering. They listed the following implications of qualitative approaches (pp. 34–35): • researchers will be able to collect authentic data that are true representations of how stuttering impacts on individuals in the real world . . . • researchers will be able to create a richer description of what stuttering is, focusing on actual behaviours, strategies, and resources employed by the PWS before, during and after moments of stuttering . . . • researchers will be able to focus on the impact of stuttering on individuals and you will be able to collect data from the perspective of the individual person who stutters . . . • researchers will be able to focus on the PWS and their collaborations with their coparticipants within the social context . . . • researchers will learn more about the phenomenon under investigation, how it operates, and how PWS attempt to reduce its impact in social contexts However, the value of a qualitative approach applied to evaluating therapeutic effect from a client’s perspective was not included in their list. A similar omission was made by Mowrer (1998) when writing on the relative benefits of various methodologies. Interestingly, he discussed the importance of parental reports in the context of childhood dysfluency but did not make any mention of client self-reporting in either the treatment of adolescents/adults who stammer or evaluating the effect of therapy. This knowledge of the personal has important ramifications for evaluating clinical practice for researchers and especially clinicians. The benefits of applying qualitative methodologies
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to client-based evaluations can be listed as following: • the collection of rich data on client reflections of the therapeutic process • comparative studies comparing client and clinicians views on how therapeutic aims/ objectives have been achieved • consideration of what part of the process of intervention is perceived by the client as affecting and/or not affecting change • the evaluation of the long term effects of therapy Thus, tending and attending to what the client has to say about his experiences, his stammer, his therapy can be enlightening and arguably of greater value to the clinician. This is especially important when both are engaged in the same therapeutic process, when experiences and perceptions can be validated and/or invalidated. This study was an attempt to engage in such a process. The aim was to gather rich data based on “personal knowledge” by asking adults who had been involved in speech and language therapy to talk about their experiences of therapy, to listen and learn from their stories, and to reflect on the effects of the intervention from their point of view. Comparisons were to be drawn between the clinician’s perceived outcomes and how these related to the clients’ own experiences, including the longer-term effects of therapy. Attempts were also to be made to identify the key features of the process that contributed to positive change in individuals.
3. Methodology 3.1. Qualitative methodology While there are several different qualitative approaches that could have been applied to this study, it was important to select a methodology that fulfilled the aims. A phenomenological approach was chosen using in-depth, semi-structured interviews carried out with a small number of individuals. Crabtree and Miller (1991) described the data generated from this type of interview as “taped stories derived from informants through several broad, open-ended questions and follow-up prompts”. A topic guide to the interview was developed, firstly by identifying important questions for consideration, then grouping these into a coherent format and finally ordering these questions in a logical way. A pilot interview was carried out using the topic guide with one male client who had attended individual and group therapy sessions from the identified service and was no longer attending therapy. The topic guide was as follows: 1. Speech — opening question: “Tell me about your speech now”. Follow-up questions were: • Level of fluency at present • Concern about stammer • Control of stammer • Ability to manage communication issues/situations which may arise in the future
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2. Speech and language therapy — opening question: “Tell me about the therapy you attended”. Follow-up questions on therapy were: • • • • • • •
Speech Ability to control speech Feelings and emotions Life style, perspectives on life and employment issues Isolation Support Self-esteem, confidence
3. The degree to which speech and language therapy fulfilled the individual’s expectations — opening question: “In what way were your initial expectations of therapy met or not met?” 4. Interactions with the speech and language therapist — opening question: “What aspects of your interaction with the therapist/s did you find most/least helpful?” 3.2. Client participants Clients were selected on the basis of being “experiential experts” in this instance, experts in the experience of a particular therapeutic intervention within a particular time frame (i.e., intensity sampling). Invitations to participate in the study were sent to 77 clients involved in group therapy, facilitated by the same two therapists, and who had been discharged from therapy between 1995 and 1999. Invitations were posted to clients’ home addresses on the basis of information held on case records at the time of discharge. Additional invitations were sent to members of the local self help group who had also had therapy and been discharged during the same period. A total of 13 clients volunteered to take part in the study. Three people failed to attend for interview. Ten people were interviewed but two did not meet the criteria for inclusion in the study. One male had not had therapy in the agreed location and a second male had therapy principally for a neurological condition. Eight client interviews formed the basis of this study. While the sample was small, the clients who took part represented a diverse group. The age range was 23–59 years, mean 41.5 years and there were a range of occupations represented (i.e., student, cabinet maker, project engineer, graphic designer, accountant, chef). Seven were male, and one was female and all had therapy within the same programme, individually with one of two specialists in dysfluency and in a group therapy setting in which the therapists worked together. Therapy comprised a combination of “speak more fluently” and “stammer more fluently” approaches and was grounded in client-centred and personal construct psychological theories and therapy. Within the therapy process clients selected techniques which were appropriate to their individual needs and stammering symptoms. Each individual experimented with using a variety of techniques in group and individual clinic settings and in their wider social interactions. Of those who volunteered to take part in the study, no individual was currently in therapy; one had been discharged in 1996 and the remainder between 1998 and 1999.
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3.3. Interviews The interviews were based on the topic guide described above, with the interviewer asking open-ended questions with some follow-up questions. However, it was made clear in the interview that other relevant issues could also be raised as necessary. The interviews were scheduled to last for one and a half hours and every effort was made by the interviewer to facilitate an open and relaxed atmosphere within the interview, to enable the adults to raise any issues they considered important to their experiences. The interviewer was not known to the clients and had not been involved in any stage of the therapy process. Six interviews took place in a “neutral” environment, i.e., a meeting room in the administrative headquarters of a local hospital, which had no connection with the location of clients’ therapy. Two interviews were held in the clients’ home, as this was more convenient for them. The interviews were taped in their entirety using a Marantz stereo cassette recorder (model CP 230) with stereo microphone (Marantz EM-8). Permission was obtained from each client to tape record the interviews prior to recording and the equipment was placed to optimise recording quality in each setting. 3.4. Analysis An independent assistant transcribed the taped narrative elicited in each interview and this transcription was then verified by the interviewer. These anonymous transcripts comprised the data used in this study. The data was subjected to qualitative analysis (Cresswell, 1998; Miles & Huberman, 1994; Moustakas, 1994). The analysis consisted of three sequential and linked processes: 1. Data reduction — in which the primary researcher and the interviewer independently summarised, coded and broke down the transcripts into themes. Notes were made at this juncture regarding the possible significance of each of the client’s response. For example, “I had a period in London when I went to the City Lit. for a year or so to a regular evening group session, because I felt in need of support at the time” was noted as “previous therapy”. (“City Lit.” is the City Literary Institute in London, which is an educational establishment responsible for running a number of adult courses including several for adults who stammer.) Some responses were allocated more than one notation, for example, “I get the feeling my fluency is better now than it was before going into therapy with T. (therapist) and the group sessions that we had” was noted as “current status of speech” and “outcomes of therapy”. 2. Data display — in which the data was organised by the researchers. In this process each researcher identified recurring themes firstly for each client and then across different clients. Not all themes were generated by all clients but it was felt to be important to note all topics at this stage. 3. Conclusion drawing and verification — in this process the independent findings of the two investigators were compared. The notations made against responses were discussed. It was observed that although the analysis had been carried out independently, there were few areas of disagreement. The researchers then discussed and agreed upon the recurring
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themes in the data. While the same major themes were identified, the names and exact content or grouping of responses under given themes required some consideration. For example, clients discussed their level of concern regarding their speech and there was a discussion as to whether or not this needed to be a separate issue or could be included in “current status”. It was agreed that the more overt features (i.e., stammering behaviours) should be included under current status and covert or psychological issues be separated under another theme, representing the emotional aspect of stammering. The first author carried out a second review of the agreed themes in relation to individual client responses. Finally, in addition to the methodological procedures outlined above, further validation of the data was carried out. To counteract possible researcher bias, the data was subjected to analysis by an independent speech and language therapist with no previous contact with the clients or involvement in the therapeutic process under review. She reviewed the transcripts and the themes that had been assigned to the responses and outlined areas, which required clarification or modification. Following her comments the data was reviewed and appropriate changes made to the categorisation of responses in relation to identified themes. Once this process had been completed the transcripts were coded according to the agreed themes and Non-numerical Unstructured Data by Indexing Searching and Theorising (NUD*IST) was used to store the transcripts electronically. NUD*IST is a leading software programme, designed by Lynne Johnson at the University of Gloucestershire in England and well established in qualitative data analysis.
4. Results A number of themes were identified using the analysis detailed above. Some issues were mentioned by only one or two individuals and these were not included in the general consideration. Themes that recurred in the interviews of all the individuals were categorised and defined as follows: 1. Current status of communication — the client’s description and evaluation of the overt features of their speech and the effect these had on their social interaction at the time of interview. 2. Covert features of stammering — the client’s description of their current experience of the less overt symptoms of stammering, for example, avoidance behaviours, anxiety related to speaking, their degree of concern about their speech. 3. Coping strategies — the client’s report of any specific management techniques used to control and/or reduce overt and covert stammering symptoms. 4. Details of content or stages of therapy process — the client’s description of their experience of the group therapy programme, including specific details of exercises, group interactions, etc. 5. Comments on speech and language therapists involved in therapy — any reference made to interactions with the therapists running the group therapy programme, including comments on therapeutic style, specific behaviours (i.e., supportive, challenging, empathetic).
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6. Support issues — comments made by clients regarding any networks of support they had experienced and the nature of the help received from others. 7. Immediate effects of therapy — those reported changes which occurred both during the group therapy programme and in the short term follow-up/review period (i.e., up to 1 month after the group). 8. Long term outcomes of therapy — changes which were sustained following discharge from therapy (i.e., reported 1 year after the group). 9. Suggestions on how the therapy programme/approach might be modified — ideas offered by individual clients regarding change to any aspect of the group therapy (e.g., timing, location, organisation, therapeutic approach, therapist style, specific exercises included in the programme). In consideration of the effect of therapy, some of these themes were considered more pertinent than others (e.g., items 7–9). These specific items were analysed in detail and reference will be made to quotations from individual transcripts in discussion of these issues in the following section. 4.1. Effects of therapy • Reduced isolation: The opportunity afforded by group therapy to meet and discuss with like-minded people was greatly valued. Of the individuals interviewed three had not had this chance previously and found it very beneficial. The effect of group therapy in reducing a sense of isolation appeared to have a lasting effect and two individuals perceived this issue to be a turning point in the therapeutic process. “I walked in, a big circle of people sitting around — a bit nerve racking to say the least. I’d never been in a situation like that before. It was really like the conversion on the road to Damascus. It was absolutely wonderful, instant light going on over my head. It was wonderful to meet other stammerers, wonderful to share experiences. From that day on it just improved”. (Mr. H) • Support: Three individuals talked positively about the contact they had with other adults who stammer. They reported a sense of loss when individuals left the group at the end of their therapy and, in some instances, discussed continuing friendships with ex-group members. “The supporting nature of the speech therapy and self help group is beyond price. To be able to support and empathetic understanding is essential. To be able to speak from direct experience is crucial. Speech therapy gave me some wonderful friends, friends who are caring and concerned and appreciate from the first hand experience exactly what it is like to live and cope with a stammer”. (Mr. A) • Improvements made in the group: seven of the eight interviewees reported on significant changes they had experienced while attending the group therapy sessions. For some this experience was “dramatic”; two individuals reported not experiencing change until they joined the group.
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“I had quite a lot of individual therapy but it was not half as effective as a group therapy. As soon as I moved into the group therapy my confidence and self esteem just went up like a rocket”. (Mr. A) For others change appeared to be linked with feelings of being at ease within a communication setting. “Towards the end I felt very comfortable. I could do anything in the group that was asked. I was fluent in the group. I felt so comfortable that I was fluent”. (Mrs. A) • Increased fluency: Most individuals (i.e., seven out of eight) perceived themselves as generally more fluent. The interviewees talked of their feelings of greater speech control in different situations as a result of therapy. There was a lack of general agreement on which techniques were helpful and people’s experiences were very different. For example, relaxation, rate control, desensitisation, focusing on the content of utterances were all described by different people as helpful. Two people thought block modification and voluntary stammering were unhelpful. • Transfer issues: It was clear that some of the group experiences did not appear to generalise to situations outside the group. There were a number of comments made on the “artificial” nature of the group. “In the group I felt confident there. Yes, it was enjoyable but it is totally different outside. It was a bit artificial”. (Mr. F) The group therapy sessions were experienced as a stark contrast with the outside world and consequently made the application of skills learnt or suggested by the group difficult to use in everyday situations and this continued after therapy had ended. There was not a sense that skills were built upon and situations became easier with time. • Maintenance strategies: A focal aspect of the group therapy sessions was the establishment of a tailor made set of strategies or “toolbox” with which each client left the group. Half of the interviewees discussed the usefulness of these strategies. One person, while able to recall specific fluency controlling techniques, could not remember his maintenance “tools”. Another individual discussed the static nature of his strategies. “I’m not convinced that speech therapy gives you the ability to continue to control your speech because if that was the case my speech should just keep on improving. It should be better than it was 4 years ago, but its not”. (Mr. E) • Long term effects: While individuals continued to experience variability in speech control, for many fluency was less of an issue of concern. “. . . it was the desensitisation that seemed to take over, and so I said to myself, “what the hell, I’m a stammerer, so what?” And I tried it and it worked. I got confidence and a lot more outgoing and I wasn’t afraid of half the things I was before I went to speech therapy. Anyway it’s just gone on from there”. (Mr. G) • Changes in attitude: Comments indicated changes both in general terms and in relation to specific situations which had previously been problematic. Individuals discussed a number of changes in relation to particular speaking situations, for example, telephoning.
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Seven clients reported significant changes in what they felt able to do. Five talked in detail about feeling less fearful in specific situations and how events generally had less impact on their ability to see themselves in a positive light. “Not much crushes me now like it used to”. (Mr. H) • Changes in life style: Not all of those interviewed felt that their experiences of therapy had affected their life style. However, half of the interviewees discussed significant changes in training and employment opportunities, and social activities. “I think that speech therapy has given me the confidence to do what I have done in terms of my employment. Going back to University, qualifications, starting work, changing jobs. So yes my speech therapy has had effects on that”. (Mr. E) “. . . going to the Himalayas. Quite a large amount of social activity is connected to that. Quite confident about that and I am really looking forward to going away. I put that down solidly as a result of going to speech therapy and it being successful”. (Mr. H) • Suggestions on how the therapy programme/approach might be modified: incorporation of other techniques into the programme: One individual criticised the programme for not incorporating the ideas of a specific independent practitioner. “So if some people like this diaphragm thing they get the benefit out of it and if some people don’t like it its good to think about it and introduce it. So it would be good to give them a handout, you know, if you are interested do this at home. Don’t just say no it won’t work. We are not interested. Anything that would help someone to regain their fluency should be considered, it’s important to us”. (Mr. C) • Counselling: It was interesting to note the difference of opinion regarding the balance of counselling and skill based therapy carried out within the group. As previously stated the therapy was grounded in client-centred and personal construct psychology. The therapists themselves had postgraduate training in a variety of psychological approaches and in particular one of the therapists was a trained counsellor. One client in particular stated that there was not enough emphasis placed on the psychological impact of stammering within therapy and went on to discuss the role of the speech and language therapist and counselling. • Generalisation/transfer of skills: This was of concern to three of the interviewees. In particular, time allocated to work on interview skills and techniques, speaking on the telephone and regular group presentations were suggested. • Additional support: Those who were interviewed made several suggestions about the nature of sessions that could be offered after group therapy. These included booster sessions/weekends, periodic, compulsory follow-up appointments, and advanced group sessions or day courses. “Exactly, for people who have actually finished. Like a day’s course, a weekend course for people who have actually completed the course. I don’t know what extra I’m looking for. It’s just that bit more. Not just fluency in my speech but fluency in my overall presentation”. (Mr. E)
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5. Discussion and conclusions There are a number of considerations regarding the client sample and the methodology. Firstly as this was a qualitative study, an exploration of individual experiences of therapy, there will be no attempt to suggest these findings are generalisable and typical of all people who stammer. While the small sample is not an issue in such an in-depth qualitative approach, the selection of the clients needs to be discussed. While every attempt was made to involve a wide range of “experiential experts”, the final group of interviewees contained a proportion of individuals who had some association with the local self help group; two were members of the group at the time of the interviews and two had been involved in the past but were not currently attending group meetings. This may have had a bearing on some of the responses made by these individuals. For example, the fact that they had some association with the self help group could be interpreted as their personal need for ongoing support which was crucial to how they managed their stammering. Thus, these individuals may have used a similar construction process in their understanding of the meaning of therapy for them (i.e., on the continuum “provides support — does not provide support”). While the individuality of the data is more important that any generalisations, it is interesting to note that these types of responses may be more typical of those clients who go on to membership of self help groups after therapy has ended. The interviews yielded detailed, personal information from those who were interviewed. It should be noted that only a small proportion of the total sample from the interviews has been discussed in this paper. The data considered here did, however, highlight a number of pertinent issues in relation to the effect of the therapeutic process. Firstly, it threw light on the importance adults who stammer place on meeting with each other and sharing experiences, without necessarily needing input from a third party. There seemed to be a lasting positive effect on individuals’ self-esteem and self-perception when they become aware that others share similar difficulties and they are not alone. The reduction in isolation effect has been noted in other therapeutic groups. For example, Yalom (1995) in his discussion of group psychotherapy talks about clients having a “heightened sense of uniqueness” which becomes invalidated in the therapy process. In the therapy group, especially in the early stages, the disconfirmation of a patient’s feelings of uniqueness is a powerful source of relief. After hearing other members disclose concerns similar to their own, patients report feeling more in touch with the world and describe the process as a “welcome to the human race” experience. (p. 6) The significance of this sharing of experiences within a group setting may often be missed by therapist bent on teaching specific fluency skills or adhering to a set programme of activities. Although the clinicians involved were aware of the function of the therapy groups in reducing isolation, the information from these interviews underlined the importance of this. As a result changes were made in the format of group sessions to maximise exchange of information and establish group support networks (e.g., telephone link schemes). Benefits of group sessions were attributed to different aspects of therapy and there did not seem to be any “universal truths” about the use of specific techniques to enhance fluency or change particular attitudes. This seems to point to the need for therapists and clients to jointly experiment with a variety of approaches and design a number of strategies appropriate for
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each individual. Following reflection by the clinicians this issue has also been incorporated more fully into group therapy sessions. The adults who talked of long term benefits of therapy included speech change, reduced anxiety in certain situations and a general “enabling”; a feeling of not being held back by speech difficulties. Of particular concern was the way some individuals felt therapy had not helped them to continue the process of change. While the clinicians were aware of the difficulties in transferring skills from a clinical setting and maintaining them in the client’s natural environment and had designed therapy around naturalistic social settings this was obviously not enough. Reflections on the interviewees comments have lead to the further development of the group therapy programme. There is now more of an emphasis on the dynamic nature of “tools” in an individual’s “toolbox”; tools that will evolve to meet the person’s changing requirements and the demands which might be placed upon him/her in the future. This approach recognises a person as constantly learning, developing and “reinventing” him or herself. Any intervention that has at its core long-term change needs to ensure the desired outcomes are also dynamic in nature. Finally, the interviewees talked a great deal about the need for ongoing support. It was not clear whether or not the inadequacy of their maintenance strategies had compounded this need or if there were other factors involved. This issue of support will continue to be reviewed with clients on discharged and at subsequent review meetings requested by clients. It does, however, raise the question of timing of discharge of adults who stammer. This study seems to suggest the need for a more flexible, open-ended approach to discharge, which is not easy to achieve within the current models of service delivery where purchasers require information on exact numbers of contacts/clinical sessions in order to agree a cost of intervention. It is interesting to compare these results with other studies that describe therapeutic factors rated as most helpful by clients in, for example, psychotherapy groups. There is considerable agreement with the most commonly chosen factors being: • • • • •
catharsis (i.e., the expression of feelings) self-understanding (i.e., discovering and accepting aspects of self previously unknown) interpersonal input (i.e., receiving feedback from others on how the self is portrayed) cohesiveness (i.e., reduced isolation) and universality (i.e., learning that other people share the same problem and concerns) (Yalom, 1995).
Aside from the specific issues that have arisen out of the data, this paper also highlights other points with regard to clinical effectiveness. The need for evaluation of effect and effectiveness of any therapeutic programme is clear. However, what form this should take has been the subject of much debate. In discussing the gap between scientific investigation and clinical practice Guitar (1999) argues for a research “attitude” in clinic. “We urge that all clinicians use the scientific method in assessing and improving their practice to help us grow as a profession”. This study has demonstrated one way in which clinicians might be informed of the effect and the effectiveness of the practice in which they are engaged but has highlighted the significance of involving clients in this evaluative process. The validity of the outcomes of the specific intervention under review has been given added weight because clients have been able to discuss their personal
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experiences of it. One might argue that the most important “gold standard” of effectiveness is one where the client perceives the outcome as of value. CONTINUING EDUCATION A qualitative study of therapeutic effect from a user’s perspective QUESTIONS 1. This study is a consideration of therapeutic effect: a. from reflections by the therapist b. by comparing therapist and client reports c. from the client’s perspective d. from objective speech measures e. from an analysis of therapeutic dynamics 2. This study used a qualitative methodology involving: a. structured interviews b. in-depth interviews c. questionnaires d. focus groups e. narrative based accounts from clients 3. Thematic analysis of the data revealed: a. therapy reduced feelings of isolation b. therapy successfully incorporated a range of ideas from various sources c. therapy promoted long term fluency gains d. therapy mirrored real life situations e. most clients continued to have negative speech attitudes 4. Results suggested some specific changes to the therapeutic programme: a. clients required a more dynamic set of maintenance tools b. clients required a more comprehensive set of therapeutic tools c. clients required greater knowledge and use of fluency skills d. clients needed stronger support networks e. clients require regular review appointments 5. The study advocates some changes to client management on discharge: a. therapists to review clients following discharge b. therapists to send letters to clients inviting them to comment on their therapy c. reflective notes to be written by the therapist(s) d. therapist to have an open ended discharge policy e. clients to set up support networks
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