Student clinicians’ and clients’ perceptions of the therapeutic alliance and outcomes in stuttering treatment

Journal of Fluency Disorders 61 (2019) 105709

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Journal of Fluency Disorders journal homepage: www.elsevier.com/locate/jfludis

Student clinicians’ and clients’ perceptions of the therapeutic alliance and outcomes in stuttering treatment

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Robyn L. Crofta, , Jennifer Watsonb a b

The University of Texas at Austin, 2504A Whitis Ave., Austin, TX 78712, United States Texas Christian University, United States

A R T IC LE I N F O

ABS TRA CT

Keywords: Stuttering Therapeutic alliance Adults who stutter Treatment Student clinicians

Purpose: The purpose of this study was to examine how the therapeutic alliances (TA) of graduate student clinicians and adult clients who stutter relate to perceived treatment outcomes. Methods: Student clinicians (N = 42) and adult clients who stutter (N = 22) completed a survey assessing their TA strength and perception of treatment outcomes. Responses were analyzed to determine similarities and differences in how clinicians and clients relate the TA to perceptions of treatment effectiveness, progress, and outcome satisfaction. Results: Results suggest that clinicians and clients who stutter both relate the TA to treatment outcome, but in different ways. While clinicians associate the TA most with treatment effectiveness and client progress, clients relate the TA most to outcome satisfaction. Conclusion: Clinicians should be aware that for adult clients who stutter, outcome satisfaction is related to the degree of shared understanding, agreement on daily tasks, and bond they experience with their clinician. To ensure a strong TA and client satisfaction, clinicians should actively seek their clients’ perspective regarding TA status.

1. Introduction The multifaceted nature of stuttering can be represented by the diverse behavioral, affective, and cognitive characteristics that people who stutter (PWS) may exhibit. Stuttering is defined as the disruption in the rate, rhythm, smoothness and overall forward flow of speech; however, the way in which tension, strain, and effort manifest in the speech of PWS differs from one person to the next (Conture, 2001; Sheehan, 1970; Van Riper, 1973). These complex physical characteristics of stuttering are compounded by its affective and cognitive components, which are invisible to the observer but can be profound contributors to a person’s quality of life. The underlying thoughts, feelings, and emotions of a PWS can manifest in avoidance behaviors (Ginsberg, 2000; Zebrowski & Kelly, 2002), psychosocial difficulties (Craig & Tran, 2014; Iverach & Rapee, 2014; Perez & Stoeckle, 2016), and/or academic and vocational challenges (Dorsey & Guenther, 2000; Klein & Hood, 2004; Zebrowski, 2016). In order to navigate the dynamic behavioral, attitudinal, and life-quality consequences that can accompany stuttering, many individuals seek treatment from speech-language pathologists (SLP). For adults who stutter, common treatment approaches include speech motor intervention, cognitive intervention, or a combination of both. While many adults who stutter report receiving treatment that integrates both approaches (Yaruss & Quesal, 2002), controversy surrounding the clinical application of these approaches dates back to the 1930s and has persisted to the present day (Nippold, 2012; Van Riper, 1982; Yaruss, Coleman, & Quesal, 2012). When considering these divergent professional perspectives in

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Corresponding author. E-mail address: [email protected] (R.L. Croft).

https://doi.org/10.1016/j.jfludis.2019.105709 Received 27 August 2018; Received in revised form 26 June 2019; Accepted 9 August 2019 Available online 14 August 2019 0094-730X/ © 2019 Elsevier Inc. All rights reserved.

Journal of Fluency Disorders 61 (2019) 105709

R.L. Croft and J. Watson

the context of the tenets of evidence-based practice, the client values and wishes become that much more significant in the clinical decision-making process for stuttering treatment (American Speech-Language-Hearing Association, 2005). Venkatagiri (2009) provided insights into the wishes of 216 adults who stutter by asking if they prefer to speak fluently or to speak freely without pressure to be fluent. The results indicated that “a majority of people who stutter appear to benefit from flexible treatment programs with cafeteria-style choices” (p. 500). This study revealed the paradox between freedom to speak and fluency, concluding that PWS crave fluency in some situations and freedom in others. More recently, Perez and Stoeckle (2016) examined available treatments for stuttering, including pharmacologic treatment (e.g., antidepressants), nonpharmacologic treatments (e.g., acupuncture), and speech therapy. Across each of these treatment options, PWS indicated speech therapy as the therapy of choice. Taken together, these findings hold serious implications for the SLP’s role in stuttering treatment. It is known PWS prefer a diverse range of treatment options, and it is also known that the SLP continues to be the primary source of guidance and support in the management of stuttering. Therefore, SLPs must consider how they can be flexible in their approach to treatment, but consistent in their provision of best care. Considering clients’ variability in goals and preferences, it is essential that SLPs and PWS work together to explore treatment approaches and to select goals that are relevant and motivating. Clarity on this collaborative process may lie beyond the therapeutic procedure and, instead, in the therapeutic alliance. 1.1. Therapeutic alliance fundamentals Distinct from the therapeutic relationship, which focuses on the feelings that the client and clinician have towards one another (Gelso & Carter, 1985), the therapeutic alliance is defined by three features: consensus on goals, agreement on the tasks during therapy, and the affective bond between the clinician and the client (Bordin, 1979). The concept of the alliance originates from the musings of Sigmund Freud, who highlighted the predicament patients face at the beginning of therapy when they feel challenged and uncomfortable, yet eager to improve (Freud, 1958; 1913). He proposed that if the client and the clinician establish a trustworthy and comforting relationship, the client will remain in therapy despite increasing levels of anxiety. The alliance is dyadic in nature, as it signifies how well the client and clinician work together to achieve common goals (Horvath, Del Re, Flückiger, & Symonds, 2011). In the field of psychotherapy, evidence to support the relationship between the therapeutic alliance and reported treatment outcomes is robust. In a study that examined clients’ views of the therapeutic alliance and its relationship to treatment outcomes, Clemence, Hilsenroth, Ackerman, Strassle, and Handler (2005) reported that patients who viewed the alliance as strong also reported improved functioning and a feeling that therapy was helpful. Conversely, a mismatch between the clinician and client perceptions of the alliance could render interventions that are perceived as less effective (Horvath et al., 2011). A synthesis of 200 research reports that reviewed more than 14,000 treatments demonstrated a strong overall aggregate relation (r = .275; p < .001) between clinician-client alliance and treatment outcomes. The magnitude of this correlation is one of the most robust that empirical research to date has documented and lead the conclusion that: The impact of the alliance on therapy outcome is ubiquitous, irrespective of how the alliance is measured, from whose perspective it is evaluated, when it is assessed, the way the outcome is evaluated, and the type of therapy involved. The quality of the alliance matters. (p. 13) The existence of factors that transcend the specific treatment procedure can also be explained by the common factors model. This model asserts that across diverse treatment options, there are commonalities that make treatment effective, regardless of the specific intervention approach. Some of these qualities may include empathy, positive regard, and the clinician-client relationship (Grencavage & Norcross, 1990). In their recent metanalysis of reports examining the therapeutic alliance, Flückiger, Del Re, Wampold, and Horvath (2018) reached similar, powerful conclusions that the influence of the therapeutic alliance on treatment outcomes is at least equal to the influence of treatment itself. 1.2. The therapeutic alliance in stuttering treatment The importance of the therapeutic alliance in stuttering treatment was acknowledged as early as the 1960s (Cooper, 1966; Manning & Cooper, 1969). While SLPs may possess knowledge of treatment techniques, many fail to understand their clients’ experience of stuttering, leading to client frustration. Manning (2004) suggested that SLPs should measure successful change “by whether or not [they] understand the client’s story and whether or not [they] meet the client’s goals rather than [their] own,” implying that the clinician-client consensus on goals – a pillar of the therapeutic alliance – is a therapeutic necessity that seems to be missing in most therapeutic contexts. Yaruss, Quesal, and Murphy (2002) further demonstrated this clinician-client disconnect and its impact on treatment retention through a stuttering experience survey that was administered to 71 adults who stutter. Ninety-four percent of the respondents had received speech treatment at some point in their lives; however, 84.5% sought treatment more than once, with 50% of these individuals doing so because they reportedly did not feel that they experienced success in treatment. When respondents were asked the cause of treatment dissatisfaction, 22.4% reported they were asked to perform tasks they did not feel comfortable doing, 11.9% felt misinformed regarding their probability of success, and 9% did not feel valued in the decision-making process. Each of these reasons for dissatisfaction directly reflects a rupture of the therapeutic alliance, specifically with regard to the “consensus on goals” and “agreement on tasks in therapy” components. The implications of these results are both sobering and empowering. Although the therapy dissatisfaction rates are high, the mismatch between the clinician and client expectations may be preventable; collaboration is a skill, not a coincidence. 2

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While the TA’s merit has been recognized anecdotally, research to support its evidence-base has emerged only recently. Plexico, Manning, and DiLollo (2010) explored the constructs of a successful therapeutic experience as defined by clients who stutter. In their phenomenological exploration of what adults who stutter value in the therapeutic process, 17 of 28 participants emphasized the importance of the therapeutic alliance in their responses. Specifically, PWS indicated that clinician empathy, trust, support, goal agreement, and competence were all conducive to successful therapy, more so than other clinician qualities, such as patience or adherence to treatment approach. Conversely, clinicians who were judgmental, lacked understanding of the experience of stuttering, and were too dogmatic in their approaches were viewed as less effective. Irani, Gabel, Daniels, and Hughes (2012) also found that one of the major factors participants reported as a contributor to their overall motivation and perceived success was their relationship with the clinician as well as perceived clinician competence. Finally, in a survey examining adult clients’ perceptions of effective stuttering treatment and clinicians, Ebert and Kohnert (2010) found that, rather than a specific quality inherent to the clinician, the clinician-client relationship led to the feeling that therapy was effective. The purpose of this preliminary study was to explore the self-reported TAs of graduate student clinicians and their adult clients who stutter, and how the TA relates to perceived treatment outcomes. Examination of the student clinician-client alliance provides insight regarding the alignment of alliance perceptions and how the alliance may impact perceived outcomes. Such information can inform both practice and training, and can ultimately advance stuttering treatment. While there is overwhelming support for the alliance in psychotherapy, little information regarding the impact of the therapeutic alliance on perceived stuttering treatment outcome, the salient constructs of the therapeutic alliance, or the degree of alignment between client and clinician perceptions exists in the stuttering literature. This exploratory study sought to increase our understanding of these constructs by addressing the following research questions and hypotheses: What is the relationship between TA and perceived treatment effectiveness, progress, and outcome satisfaction for student clinicians treating adult clients who stutter? What is the relationship between TA and perceived outcomes for adult clients who stutter? Considering the previous research on differing perceptions of the therapeutic experience based on clinician or client role (Clemence et al., 2005; Horvath & Greenberg, 1986), the authors hypothesized that clinicians and clients would relate the therapeutic alliance to perceived outcomes differently. For clients, the TA would be of greater importance in all areas of treatment outcomes. TA would be of less importance to student clinicians across perceived outcomes. Study results could reveal the nature of the therapeutic alliance between student clinicians and their adult clients who stutter and its impact on perceived treatment outcomes. Results hold implications for the clinician-client interaction in stuttering treatment and clinical training for future SLPs. 2. Material and methods To examine graduate student clinicians’ and adult clients’ who stutter perception of the TA and therapy outcomes, a Qualtrics survey was developed and sent to ASHA accredited speech-language pathology programs in the United States. 2.1. Recruitment To promote an equal and robust number of student clinician and client responses, potential participants were recruited as dyads. An email with the Qualtrics survey was sent at the end of academic terms to the clinical directors of 261 SLP programs. The email provided a general purpose of the project, highlighting the need for student clinician – adults who stutter dyads. Clinical directors were asked to identify eligible dyads in their program, and to send each dyad a link to the survey, which was embedded in the email, within the last two weeks of the academic quarter or semester. Respondents were asked to complete the survey no later than one month after the completion of treatment for that academic term. In addition to the email, program contacts were also recruited via telephone. Within the conversation or voice message, the language in the recruitment email was used to describe the study’s purpose and procedure, and contacts were encouraged to reference their email for a direct link to the survey. 2.2. Participants Participant eligibility was described in the recruitment email and included: Graduate student clinicians: A.) Enrollment in an accredited speech-language pathology graduate program B.) Concluding (within one month after the last day of therapy) their treatment of an adult (≥18 years) who stutters Clients – Adults who stutter (AWS): A.) Diagnosis of stuttering by a certified SLP B.) 18 years old or older C.) Concluding (within one month after the last day of therapy) or just received treatment from a graduate student clinician Since little is known about how student clinicians and clients who stutter perceive the therapeutic alliance relative to treatment outcome, all student clinicians and clients who met the aforementioned criteria were included, even if their counterpart did not 3

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complete the survey. Therefore, participant inclusion did not rely on participation from both members of the clinician-client dyad. 2.3. Consent An informed consent document, which outlined the general purpose of the study, the known associated risks and benefits, the anonymity of responses, and the freedom to stop the survey at any time, was shown as the first page of the survey. Participant benefits included the opportunity to reflect on their therapeutic process, possibly leading to greater clarity and understanding about their experience. Furthermore, participants were provided with the author’s contact information and could contact the author to learn of the study’s results. If the clinician and client did not have a positive relationship, a risk associated with this study was the individual’s feeling of negative emotions throughout the survey-taking experience. Otherwise, there were no known risks associated with participating in this study. The document also informed potential respondents that their current or future status as students, clinicians, or recipients of therapy would not be affected by their participation in the study. An email and phone number were provided for potential participants to contact if they had any questions. Participants indicated their consent by clicking on the “ > > ” arrows at the bottom of the page, which lead to the start of the survey. 2.4. Measures The Qualtrics survey collected demographic information, responses to questions examining the TA, and responses to questions examining perceived treatment outcomes. 2.4.1. Demographic questions After providing informed consent but prior to starting the survey itself, the AWS were asked to provide the initials of their clinician, and the graduate clinicians were asked to provide the initials of their clients. Both parties were asked to provide the name of their university. The combination of these initials and the university served as a code for the authors to match dyads without being able to identify the participants’ identities. For both the client and student clinician, the following information was obtained: age, gender, number of treatment sessions that term, client stuttering severity as reported on a scale from 0 to 9 (O’Brian, Packman, & Onslow, 2004), and types of tasks included in therapy. Participants selected tasks from the following options, which were used in a previous study examining treatment in adults who stutter (Yaruss et al., 2002): techniques to speak fluently, reducing avoidance and/or fear of stuttering or speaking situations, learning to stutter with less effort, thoughts and/or emotions related to stuttering, or other. In addition, the cumulative number of months of previous treatment settings and in which settings (i.e., school, hospital, private practice, university clinic, other) was obtained from clients. For the student clinicians, questions regarded the number of months in graduate school, completion of stuttering and counseling coursework, and previous experience treating PWS. 2.4.2. Therapeutic alliance measures Modified versions of the Combined Alliance Short Form – Therapist version (CASF-T) and Patient version (CASF-P) were included in the Qualtrics survey to assess the clinicians’ and clients’ perceptions of the TA. These measures were originally designed to examine clinicians’ and clients’ perspectives independent of their counterpart’s perspective (Hatcher & Barends, 1996; Hatcher, 1999). Both have been used extensively in the field of psychotherapy and assess the therapeutic alliance while reflecting the inherent differences in clinicians’ and clients’ roles in the therapeutic process (e.g., Ackerman, Hilsenroth, Baity, & Blagys, 2000; Clemence et al., 2005; Gold, Hilsenroth, Kuutmann, & Owen, 2015; Hatcher & Barends, 1996; Hatcher, 1999; Hilsenroth, Peters, & Ackerman, 2004; Siefert, Hilsenroth, Weinberger, Blagys, & Ackerman, 2006; Siegel & Hilsenroth, 2013). The tools were modified to reference the term “client” rather than “patient” and “clinician” rather than the “therapist” in all items and in the tool and subscales titles. For clarity purposes, the tools are referred to as the Combined Alliance Short Form – Clinician (CASF-Clinician) and Combined Alliance Short Form – Client (CASF-Client). The CASF-Clinician (i.e., CASF-T) is a 40-question assessment that was created from a principal components analysis (Hatcher, 1999). This scale blends two alliance measures including the Working Alliance Inventory – Form T (WAI-T; Horvath & Greenberg, 1989) and the California Psychotherapy Alliance Scales – Therapist Version (CALPAS-T; Marmar, Weiss, & Gaston, 1989). The measure contains eight subscales and ratings are reported on a seven-point Likert-type scale ranging from 1 (never) to 7 (always). The subscales include: (1) Shared Goals, (2) Bond, (3) Goals and Tasks, (4) Clinician Confidence, (5) Client Working Engagement, (6) Clinician Understanding and Involvement, (7) Client Confidence and Commitment, (8) Clinician Confident Collaboration. See Appendix A for descriptions of each subscale. Hatcher (1999) found Cronbach alpha coefficients ranging from .75 to .88 for these subscales, and Clemence et al. (2005) found Cronbach alpha co-efficient ranging from 0.74 to 0.90, supporting the reliability of the measure. The CASF-Client (i.e., CASF-P) is a 20-item assessment of the therapeutic alliance from the client’s perspective. Hatcher and Barends (1996) created the measure from a factor analysis of three widely-used measures of alliance: the Penn Helping Alliance Questionnaire (HAQ; Alexander & Luborsky, 1986; Luborsky, Crits-Christoph, Alexander, Margolis, & Cohen, 1983), the Working Alliance Inventory (WAI; Horvath & Greenberg, 1989, 1986), subscales: (1) Confident Collaboration, (2) Goals and Tasks, (3) Bond, and (4) Idealized Clinician (see Appendix A). Items are rated on the same seven-point Likert scale as described for the CASF-Clinician. Cronbach’s alpha coefficients ranging from 0.84 to 0.91 for the subscales and .93 for the total scale have been found (Ackerman et al., 4

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Table 1 Characteristics of student clinician and client participants. Characteristic

Age M (SD; range) Gender

Males Females

No. academic programs represented Client Stuttering Severity M (SD; range) No. of Therapy Sessions M (SD; range) Therapeutic tasks

Avoidance Reduction Techniques to speak fluently Stuttering with less effort Thoughts and emotions Other Previous tx experience Yes No No. of Months in Graduate Program M(SD; range) Completed stuttering coursework Yes No No. of Months learning about stuttering M(SD; range) Completed counseling coursework Yes No No. of Months learning about counseling M(SD; range) Previous experience treating PWS Yes No

Student Clinicians (N = 42)

Clients who stutter (N = 22)

24.23 (2.78; 21-34) 3 (7.3%) 38 (92.7%) 24 4.45 (1.68; 2-9) 14.20 (6.28; 7-28) 30 (75%) 28 (70%) 20 (50%) 33 (82.5%) 10 (25%) -

29.09 (11.69; 18-56) 16 (72.7%) 6 (27.3%) 14 5.59 (2.1; 2-9) 14.09 (6.87; 5-30) 13 (59.1%) 19 (86.4%) 10 (45.5%) 15 (68.2%) 2 (9.1%) 17 (77.3%) 5 (22.7%) -

10.88 (5.46; 3-20) 29 (69%) 13 (31%) 2.3 (2.15; 0-8) 27 (64.3%) 15 (35.7%) 1.04 (1.78; 0-9) 2 (4.8%) 40 (95.2%)

-

Note. Tx = treatment.

2000), suggesting measurement reliability. 2.4.3. Treatment outcomes Perceived treatment outcomes and outcome satisfaction were measured on a 1–5 scale with labeled anchors provided on numbers 1 and 5. Labeled anchors depended on the outcome measure in question. For treatment effectiveness, clients were asked, “In your opinion, how effective was your treatment this term?” while clinicians were asked, “In your opinion, how effective was your client’s treatment this term?” For this response, 1 was labeled “Not at all effective” and 5 was labeled “Extremely effective.” For progress, clients were asked, “In your opinion, how much progress did you make on your treatment goals this term?” while clinicians were asked, “In your opinion, how much progress did your client make on his/her treatment goals this term?” On this scale, 1 was labeled “No progress” and 5 was “A lot of progress.” Finally, for outcome satisfaction, clients were asked, “How satisfied are you with the outcomes of your treatment this term?” and clinicians were asked, “How satisfied are you with the outcomes of your client’s treatment this term?” For this response, 1 was labelled “Extremely dissatisfied” and 5 was labelled “Extremely satisfied.” 3. Results Respondents included 42 student clinicians and 22 adult clients who stutter. Since inclusion in the study did not depend on participation from a student clinician or client who stutters’ counterpart, the following results represent groups of student clinicians and clients who stutter who did not necessarily experience the same therapeutic process. Complete descriptions of the participants can be found in Table 1. Prior to completing analyses related to specific research questions, the reliability of the Overall TA scores (i.e., the mean of all items for each respondent) was examined. Cronbach alpha coefficients for the CASF-Clinician and CASF-Client Overall TA were .889 and .902, respectively. These results suggested that the CASF-Clinician and CASF-Client were highly reliable measures of clinicians’ and clients’ TAs in the current study. 3.1. Exploratory data analysis and analytic approach Prior to conducting the primary analyses, preliminary and exploratory analyses were conducted to assess the obtained data, assess the assumptions of parametric analyses, and describe the final sample. The overall sample size was limited (n = 64). Given the limits in overall sample size, Likert type data likely lacked sufficient variability to be treated as continuous as opposed to categorical ranks. As such, linear relationships were assessed using nonparametric Spearman’s rho correlations. Furthermore, due to potential concerns of low observed power, consistent with the recommendations of Sullivan and Feinn (2012), results were interpreted to focus on a combination of both statistical significance as well as the magnitude of observed relationships. The effect size associated with nonparameteric correlations is Spearmans rho and is interpreted similarly to parametric correlations (i.e., Pearson’s r) with relationships less than .40 being described as weak, .40–.59 as moderate, and .60 and higher as strong to very strong (Evans, 1996). Due to the limited sample size as well as multiple comparisons utilized, risk between Type I and Type II errors needed to be 5

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Table 2 Means (SD;range) and Spearman’s Rho correlations (p value) between CASF-Clinician scores and perceived outcomes (N = 37). CASF-Clinician Subscales

Overall TA Shared Goals Bond Goals and Tasks Clinician Confidence Client Working Engagement Clinician Understanding and Involvement Client Confidence and Commitment Clinician Confident Collaboration M (SD; range)

Treatment Outcome Measurements Effectiveness

Progress

Satisfaction

M (SD; range)

.377 (.021) .445* (.005) .285 (.088) .031 (.857) .456* (.005) .379 (.021) .368 (.025) .131 (.440) .197 (.243) 3.9 (.63; 3–5)

.332 (.045) .277 (.097) .367 (.026) .119 (.483) .218 (.195) .259 (.122) .281 (.093) .078 (.647) .232 (.166) 3.95 (.75; 2–5)

.263 (.115) .357 (.030) .308 (.064) −.041 (.810) .247 (.140) .297 (.074) .266 (.111) .071 (.675) .199 (.237) 4.23 (.58; 3–5)

5.84 (.47; 4.93–6.8) 5.95 (.55; 4.83–7) 6.35 (.52; 5.5–7) 5.75 (.88; 2.3–7) 5.81 (.72; 4–7) 5.44 (.69; 4–6.8) 5.97 (.46; 4.8–6.6) 5.71 (.75; 3.8–7) 5.74 (.68; 4.2–6.8)

Note. TA = therapeutic alliance. * Indicates significance at the Bonferroni-adjusted p-value .05/9 = .006.

balanced. The compromise approach (Faul, Erdfelder, Lang, & Buchner, 2007; Prajapati, Dunne, & Armstrong, 2010) was used to maximize possible power (Type II error) within the current analyses while also utilizing a Bonferroni adjustment to account for multiple comparisons within sets of analyses (Type I error). Specifically, this balance was obtained by treating each set of correlations as separate analyses and adjusting using a Bonferroni approach by a single indicator rather than the entire correlation matrix as one set of analysis. Details of the specific adjustment by analysis are outlined in results Tables 2 and 3, respectively.

3.2. Relationship between TA and perceived outcomes A summary of the correlations for clinican report are shown in Table 2. As shown, Effectiveness was significantly and positive correlated with Shared Goals (rho = .445) and Clinician Confidence (rho = .456). None of the remaining correlations were significant at the .006 level. A summary of the correlations for client report and perceptions of treatment outcomes are outlined in Table 3. As shown, Overall TA had a moderate positive relationship with satisfaction (rho = .563). The relationships between the individual components of TA and satisfaction were also evaluated. Strong relationships were found between Confident Collaboration (.622) and Bond (.604) on satisfaction. Overall TA was not significantly associated with effectiveness or progress, all ps > .05. Confident Collaboration was significantly associated with effectiveness with a moderate positive correlation noted (rho = .580). None of the individual components were significantly associated with progress, all ps > .05. Table 3 Means (SD;range) and Spearman’s Rho correlations (p value) between CASF-Client scores and perceived outcomes (N = 22). CASF-Client Subscales

Treatment Outcome Measurement Effectiveness

Overall TA Confident Collaboration Goals & Tasks Bond Idealized Clinician M (SD; range)

.380 (.089) .580* (.006) .113 (.626) .327 (.148) .151 (.513) 3.95 (.65; 3–5)

Progress .161 (.496) .348 (.132) .135 (.569) .113 (.636) −.079 (.741) 4 (.89; 2–5)

Note. TA = therapeutic alliance. * Indicates significant at the Bonferroni-adjusted p-value .05/5 = .010. 6

Satisfaction *

.563 (.008) .622* (.003) .534 (.013) .604* (.004) .057 (.806) 4.18 (.85; 2–5)

M (SD; range) 5.98 (.66; 4.6–7) 5.52 (.88; 3.8–7) 6.27 (.77; 4.8–7) 6.03 (.82; 4.4–7) 6.08 (.73; 4.2–7)

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4. Discussion The purpose of this exploratory study was to examine how graduate student clinicians and adult clients who stutter relate the TA to perceive treatment outcomes. Given the limited sample size, results are preliminary and warrant further investigation. Reported results and interpretation are intended to provide direction for further discovery rather than conclusive evidence. Preliminary results confirmed the researchers’ hypothesis that clinicians and clients would both associate the TA with perceived outcomes; however, the researchers’ hypothesis was not confirmed in that clients did not seem to demonstrate a stronger association between TA and all perceived outcomes when compared to student clinicians. Rather, clinicians and clients both associate the TA with positive treatment outcomes, but in different ways. The relationship between TA and perceived outcomes, similarities and differences in clinician-client perceptions, and implications for clinical coursework, education, and supervision are discussed. 4.1. TA and perceived treatment effectiveness While clinicians relate a variety of clinician-oriented (e.g., Clinician Confidence), client-oriented (e.g., Client Working Engagement), and collaborative (e.g., Shared Goals) factors to treatment effectiveness, clients’ perceptions of effectiveness are most related to the belief in a therapeutic process that feels promising and helpful (i.e., Confident Collaboration). Clinicians working with adults who stutter should be aware that clinicians and clients differ in their views of the TA and its relationship to treatment effectiveness. These associations between perceived treatment effectiveness and clinician and client ratings of TA also have been found in previous psychotherapy research (Hatcher & Barends, 1996; Hatcher, 1999). Further, these results are consistent with Plexico et al.’s (2010) phenomenological study in which adult clients who stutter described an effective clinician as one who conveys a sense of belief and confidence in therapy, i.e., supporting a “confident collaboration.” Findings from the current study expand the value of a confident collaboration as one that not only relates to perceived clinician effectiveness, but treatment effectiveness as well. Clinically, this finding holds implications for facilitating the therapeutic process. Since clients’ perception of treatment effectiveness stem from a belief that therapy works, clinicians may need to provide opportunities to support the client’s beliefs in the therapeutic process and confidence that the process will lead to change. To this end, the clinician may consider providing rationales for therapy tasks, highlighting tangible changes in a variety of affective, cognitive and/or behavioral domains, and creating occasions for success outside of the therapy room. 4.2. TA and perceived progress Clients who stutter did not associate the TA with perceptions of progress, which diverges from findings in the psychotherapy literature (Clemence et al., 2005; Hatcher & Barends, 1996). Several factors may account for the difference between client perceptions of progress in the current study and previous reports. As with all results discussed, research regarding TA and perceived treatment outcomes in the area of stuttering is scarce. Therefore, while the psychotherapy literature provides a preliminary comparison for current findings, it is important to consider the fundamental differences in the patient populations when interpreting the results. Characteristics that are unique to stuttering, such as its early onset and chronicity, overt behavioral components, social stigma, and affective/cognitive reactions, may influence clients who stutter to view progress differently than patients in psychotherapy. 4.3. TA and outcome satisfaction While clinicians’ responses did not indicate significant relationships between the TA and outcome satisfaction, clients’ responses indicated greater outcome satisfaction when they experienced an overall strong TA, confidence and commitment to the therapeutic process, and mutual liking and respect towards their clinician. Unlike clinicians, clients who stutter closely associate the TA and its components with outcome satisfaction. This suggests that clinicians might feel satisfied with therapy without perceiving a strong alliance, or feel dissatisfied with therapy but still perceive a strong TA. Contrarily, it is less likely that a client would experience a weak, collaborative relationship with their clinician and still be satisfied with therapy. Furthermore, for clients, Bond was unrelated to the other two outcome measures in this study (i.e., perceived effectiveness and perceived progress), suggesting that the affective component of therapy is uniquely related to outcome satisfaction. The salient relationship between Bond and client satisfaction is supported by the healthcare quality theory (Donabedian, 1980), which posits that a patient’s expression of satisfaction or dissatisfaction is uniquely related to the interpersonal component of care. As results indicate, clinicians’ and clients’ outcome satisfaction is influenced by different factors. Therefore, in the clinical context, clinicians should suspend their own beliefs regarding what makes treatment outcomes satisfying or unsatisfying and, instead, seek their clients’ perspective regarding outcome satisfaction. Doing so could lead to treatment that better satisfies the clients’ wishes. 4.4. Explanations and implications of therapeutic alliance differences One possible explanation for the differing clinician-client perspectives regarding the TA’s relationship to outcome lies in how clinicians and clients view the function of the TA in stuttering treatment. While clinicians seem to view the TA as a bridge to better treatment (i.e., treatment effectiveness), clients view the alliance as a bridge to a helpful connection and process. Clinicians might 7

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pursue a strong alliance for the sake of increasing the effectiveness of treatment, while clients might invest in the TA because they value the collaboration, shared agreement, and interpersonal connection. These moment-to-moment interactions, rather than outcomes alone, influence the client’s satisfaction. Therefore, while perceived treatment effectiveness, perceived progress, and outcome satisfaction may be related, they also seem to be independent constructs. Clinically, this finding implies that measuring client satisfaction may have less to do with the outcomes themselves, and more to do with the client’s day-to-day engagement with the therapeutic process.

4.5. Pedagogical implications Considering the TA’s origins in psychotherapy and relatively recent application to speech-language pathology, it is likely that information regarding the TA in the therapeutic process is not routinely integrated in the pedagogy of future SLPs. The evidence regarding client dissatisfaction with stuttering treatment (Manning, 2004; Yaruss & Quesal, 2002) and perceived lack of clinician competence (Brisk, Healey, & Hux, 1997; Tellis, Bressler, & Emerick, 2008) underscores the potential value of integrating the TA into the undergraduate and graduate coursework of SLP students. Doing so may heighten students’ awareness of the importance of the TA, and ultimately, client satisfaction. Coursework might also educate students about clinician-client differences in the perception of the TA. Previous research suggests that clinicians tend to appraise the alliance according to theory, whereas clients tend to be more candid and subjective (Bachelor, 2013). While theoretical background is necessary and important knowledge for SLP students to gain, Horvath and Greenberg (1986) suggest that the clients’ “naïveté” might allow for a more accurate reflection of the therapeutic process. Clients’ responses regarding the TA have also been found to have the strongest association with therapy outcomes, whether outcome is assessed by clients, clinicians, or observers (Bachelor, 2013; Hatcher & Barends, 1996). Therefore, SLP students might benefit from coursework that teaches skills to balance theory with reality. Doing so could lead to more calibrated clinician-client perceptions of alliance and outcome in the clinical setting.

4.6. Additional considerations As noted, this study is exploratory in nature. Reported results and corresponding interpretations warrant further investigation. Results should be interpreted with the caution and understanding that this study represents only a small sample of a much greater population and focused on student clinicians. Additionally, much of the TA literature that exists is based on the psychotherapy population; therefore, studies in the area of stuttering must be replicated and performed with larger sample sizes and include practicing clinicians to ensure clinical relevance. Since current enrollment in therapy was a requirement for study participation, each client participant experienced a TA that was strong enough to still be in therapy. Overall, it was found that clinicians and clients view the TA fairly positively. While this finding is consistent with past research, which has also reported high means with few negative perceptions expressed (Bachelor, de Grace, & Pocreau, 1991; Gaston, 1991; Hatcher & Barends, 1996), the data reported do not include the perspectives of those who have discontinued treatment. It is possible that different relationships between TA and perceived outcome would be captured by surveying adults who stutter who are no longer in therapy. Future studies also may examine how the TA relates to specific changes in affective, cognitive and behavioral outcomes rather than perceived outcomes. There is evidence in psychotherapy to suggest that the clients’ views of the TA, rather than the clinicians’ views, are more predictive of actual therapeutic outcome (Horvath & Bedi, 2002). This hypothesis would be worth exploring in the area of stuttering. Research in psychotherapy has found that a client’s reported interpersonal relationships and quality of daily life predicted the quality of the TA as well as therapeutic change (Kazdin & McWhinney, 2018). Exploring the interpersonal relationships and quality of daily life in the stuttering population could lead to another dimension of prognostic indicators in treatment. Evidence has also suggested that psychotherapists’ emotional intelligence, including emotion-management and emotion-understanding skills, may reduce patient drop-out rates and facilitate the development of a strong clinician-client alliance (Kaplowitz, Safran, & Muran, 2011). The relationship between a clinician’s emotional intelligence and treatment outcome ratings should be explored in stuttering treatment to better inform clinical training and supervision methods. Finally, future studies might explore predictors of the development of a strong TA, as well as the relationship between TA and outcomes among clinicians and clients who experienced the same therapeutic process.

5. Conclusion To achieve optimal partnership, and with it, greater client satisfaction, clinicians should seek their clients’ perspective regarding the therapeutic alliance. Clinical coursework, training, and supervisors should consider supporting future SLPs by advancing skills relative to the TA, such as belief suspension and the ability to balance clinical theory with the subjective clinical experience. The TA is shaped through every clinician and client interaction and reaction, and its complexity should not be underestimated. While this study offers evidence regarding the relevance of the TA in stuttering treatment, and in particular, its relation to client satisfaction, future research should explore explicit behaviors that enable clinicians and clients to achieve a strong and aligned alliance. 8

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Disclosure of financial interest This research was completed as a thesis while Croft was enrolled as a Master’s student at Texas Christian University. Watson is a faculty member at this institution. Both Croft and Watson received financial support and/ or compensation as a graduate student and faculty member from Texas Christian University. Acknowledgements This study was completed with the help of program directors, clinical directors, and fluency clinic supervisors at Communication Sciences and Disorders graduate programs around the United States. Their help in forwarding the survey to eligible participants was critical for the completion of this project. Thank you to all of the graduate student clinicians and adult clients who stutter who participated. This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Appendix A. Therapeutic alliance subscales and descriptions

Combined Alliance Short Form- Clinician Shared Goals Bond Goals and Tasks Clinician Confidence Client Working Engagement Clinician Understanding and Involvement Client confidence and Commitment Clinician Confident Collaboration

The clinician and client’s mutually achieved understanding of goals and treatment Clinician’s liking, appreciation, and respect for the client Clinician’s need to clarify the purpose and tasks of the sessions; the perception that the client finds therapy to be confusing Clinician’s confidence that the clinician and the therapeutic work will help the client change Clinician’s perception that clients examine contributions to problems and make productive use of the clinician’s comments Clinicians’ abilities to be tactful, nonjudgmental, understanding and committed to help Clinician perception that client is confident in and committed to treatment Clinician’s perception of the client’s steadfast and confident investment in a treatment that feels promising and useful to both parties

Combined Alliance Short Form – Client Client Confident Collaboration Goals and Tasks Bond Idealized Clinician

Client is confident in and committed to a process that feels promising and helpful Clarity of duties and agreement on goals and tasks The feeling of mutual liking and respect Client’s ability to acknowledge disagreement with and negative feelings toward their clinician

Adapted from Hatcher & Barends (1999), Clemence (2005), and Gaston & Marmar (1991).

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Robyn Croft, M.S., CF-SLP is a doctoral student at the Michael and Tami Lang Stuttering Institute at the University of Texas at Austin. Her research interests include the examination of stuttering stigma reduction techniques, clinician-client communication in stuttering treatment, and the development of innovative clinical training methodologies. Jennifer B. Watson, Ph.D., CCC-SLP, BRS-FD, is a Professor in the Davies School of Communication Sciences and Disorders at Texas Christian University, where she has served as department chair and clinic director. Dr. Watson provides didactic and clinical instruction in the nature and treatment of stuttering at TCU. Her research interests include examining cross-linguistic and cross-cultural influences on the nature and treatment of young children who stutter.

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