Ego-State Change and Objective Fluency Measures in Stuttering Therapy

William S. Rosenthal
Shannon N. Austermann
Liz Rud

Department of Communicative Sciences and Disorders
California State University, Hayward

(Paper presented at the Annual Convention of the American Speech-Language-Hearing Association, November 2001, New Orleans, LA)

INTRODUCTION

In previous work we have discussed the theoretical relationship between scripts, ego states, and stuttering therapy. That work was supported mainly by case studies but included a preliminary computational analysis that showed a change in ego state over the course of stuttering therapy (Rosenthal, 1997, 1998, 2001). The present research project systematically extends the investigation of those relationships by using archival data collected over 30 years ago as part of another research project (Naylor & Rosenthal, 1968). In that project, samples of speech were collected on 16mm film of 32 active duty military personnel, who were referred for stuttering therapy at the Army Audiology and Speech Center at the Walter Reed Army Medical Center in Washington, D.C. Each participant was filmed under several speaking conditions both before and at the conclusion of the therapy program. In 1997, the films were converted to digital media, and new VHS tapes were produced for each subject. The subjects participated in an eight-week, intensive in-patient treatment program that was based on a modification approach similar to that described by Van Riper (1973) and currently used by SSMP (Breitenfeld & Lorenz, 1989). The latter program is described and reviewed by De-Nil, Kroll, & Ham (1996).

METHOD

Subjects

The subjects for this study were 32 young adult stutterers who were on active duty in military service. There were 31 males and one female. The subjects were those participants of a larger research project for whom complete recorded data of both pre- and post-therapy were available (Naylor & Rosenthal, 1968). The ages of the subjects in the larger study ranged from 18 to 35 with a mean age of 24 years. The subjects, who were referred for stuttering therapy at the Army Audiology and Speech Center at the Walter Reed Army Medical Center in Washington, D.C., participated in an eight-week, intensive in-patient treatment program that was based on a modification approach similar to that described by Van Riper (1973). Each participant was recorded under several controlled speaking conditions, before and at the conclusion of the therapy program. These included one minute of reading, two minutes of spontaneous speech, and a one-minute telephone call. Samples of speech were originally collected for each subject on

16mm film that was produced from video taped recordings. For the present study, the original films were converted to digital media and both the video and audio signals were enhanced electronically. New VHS master tapes were produced for all subjects, resulting in a set of 64 pre- and post-therapy segments of approximately five minutes each.

Analyses

For the current research project, several analyses were conducted.

Ego-State Analysis

Each subject's predominant ego state was assessed from the visual record and from the content of transcripts of the pre- and post-therapy videos following procedures described in an earlier paper (Rosenthal, 2001). Ego state constructs, as defined by transactional analysis theory, were used (Berne, 1961). These include Adult (A), Adapted Child (AC), Natural Child (NC), Nurturing Parent (NP), and Critical Parent (CP). Ego states are measurable using dimensional scales that evaluate facial expressions, body posture, intonation patterns, as well as word choice and sentence structure (Dusay & Dusay, 1989). The premise, supported by previous work is that changes in the predominate ego states of individuals occur as therapy proceeds. Specifically, successful therapy outcome is accompanied by increases in the representation of the Adult ego state and the reduction of the Adapted Child ego state (Rosenthal, 2001).

Treatment Success

Separate clinical ratings were made of the success of each subject in attaining the goals and objectives of the stuttering modification treatment program, as described by Naylor & Rosenthal (1968) and Rosenthal (2001). Severity ratings were made on a seven point, equal-appearing interval scale from "Very Mild" to "Very Severe". Seven criteria were applied to the rating of each subject and segment: (1) Indications of excessive muscle tension while stuttering, (2) Indications of inefficiency, or undue delay in releasing tension, (3) Attempts to avoid or postpone stuttering, (4) Inappropriate movements while stuttering that are conspicuous and distracting, (5) Instances of inappropriate rate associated with stuttering, (6) Instances of failure to initiate or maintain eye contact with the camera while stuttering, and (7) Instances of inappropriate loudness, pitch, or voice quality associated with stuttering.

Objective Measures

Objective measures of fluency rate, types of dysfluencies, and concomitant behaviors were obtained using an adaptation of the Stuttering Severity Instrument (SSI) (Riley, 1980). For the current study, Stuttering Disfluencies (SD) were defined as part word repetitions, sound and syllable repetitions at the beginning of words, audible prolongations, inaudible blockages, and cessations of phonation. A separate category of Indeterminate Disfluencies (ID) was established. This category included whole word repetitions (mono and polysyllabic), phrase repetitions, interjections, extraneous words, filled pauses, and stereotyped starters. A third category, Concomitant Behaviors (CB), included distracting sounds (noisy breathing, whistling, sniffing, blowing, or clicking sounds), facial grimaces (jaw jerking, tongue protruding, lip pressing, or jaw muscles tensing), head movements (moving back or forward, turning away, making poor eye contact, or constant looking around), and movement of extremities (arm and hand movement, hands about face, torso movement, leg movements, or foot tapping or swinging). Only the total of all types of Concomitant Behaviors exhibited throughout the speech sample was recorded, rather than the rate per number of words, as was the case with all other measures. In addition, Words Per Minute (WPM) and Total Words (TW) were counted for each of the two minute samples.

These three sources of information were examined to determine if the SSI-like objective measures were related to changes in the subjects' predominant ego states and to treatment outcome ratings. Two raters, including the senior author, completed preliminary ego-state analyses. The senior author and two other raters trained by the senior author completed the clinical ratings of the success of each subject in attaining the goals and objectives of the treatment program. Both of these raters were graduate students in speech-language pathology and were confirmed adult stutterers who had participated in treatment programs similar to the one described in this study. Two additional raters, trained by the senior author, completed the objective counts from the tapes and transcripts of each subject. Both were graduate students in speech-language pathology and had completed an academic course in fluency disorders.

RESULTS

Three research questions were addressed. First, is there a change in objective measures from pre- to post-therapy? Second, is that change related to treatment success? Third, is there an association between changes of objective measures and changes of ego states before and after therapy?

Overall Change

Statistically significant changes between pre-therapy and post-therapy were noted for the measures of speech output: Total Words per Minute and Total Words in the sample. Both increased over the course of treatment. Indeterminate Disfluencies (ID) and Concomitant Behaviors (CB) decreased significantly over the course of treatment. Although Stuttering Disfluencies (SD) decreased, the difference was not statistically significant. These results are summarized in Table 1 and illustrated in Figure 1. In the figures, the measures of speech output are shown with the actual values divided by 10 in order to improve the visual appearance of the graphic data.

Changes Related to Treatment Success

For these analyses, the experimental group was subdivided into two subgroups, High Success (N=21) and Low Success (N=11), following the procedures described in previous work (Rosenthal, 2001). When compared with the Low Success Group, the High Success group showed a significant increase in speech output as measured by Total Words, and significantly decreased Stuttering Disfluencies. While the other measures changed in the expected direction, the differences were not statistically significant. These results are summarized in Table 2 and illustrated in Figure 2.

Objective Measures Related to Ego State Changes and Treatment Success

The relationships between Ego State measures, Treatment Success, and Objective Measures were explored using correlation analysis. This analysis (Table 3) shows that there is a moderate positive correlation between measures of verbal output and increased Adult Ego State. Conversely, there is a moderate negative correlation between measures of verbal output and Adapted Child Ego State. While those results are in the predicted direction, there is no significant relationship between ego state change and the other objective measures of speech disfluency or concomitant behaviors. On the other hand, moderate to moderately-high positive correlations were found for all objective measures and the independent measure of treatment success (see Table 3).

Predictive Model

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

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

Finally, we regressed all variables (ego state variables and objective variables) against treatment outcome. The results, shown in Table 4, show a maximum R of .81 when all variables are accounted for. However, most of the variance in this model is due to a combination of all objective measures and a single ego state measure, Nurturing Parent. The corresponding multiple R is .79. The addition of the remaining ego state measures increases the predictive efficiency of the model by only 3.8%.

DISCUSSION

The purpose of this study, and its predecessor (Rosenthal, 2001) was to look for possible relationships between ego states and objective measures, and the outcome of stuttering therapy. The premise presented earlier (Rosenthal, 1997, 1998) is that early adaptations to stuttering that begin in childhood are usually not conducive to successful management of the problem in adulthood. Successful therapy likely hinges on freeing individuals from those early adaptations and replacing those adaptations with intentional, adult ego state functions. While this hypothesis was somewhat supported in the earlier work, the relationships were not strong. A predictive model accounted for only 32% of the treatment outcome variance. Furthermore, the particular ego states that emerged as significant were not exactly those that were predicted. The regression models included in the current study showed that nearly 50% of the variance associated with treatment outcome was accounted for by objective measures, mainly verbal output as measured by Total Words and Words per Minute. When all variables from both studies were included in the analysis, the predictive efficiency increased to account for about 66% of the variance associated with treatment outcome. However, the main contributor was the combination of objective variables.

Studies of stuttering treatment are fraught with difficulty and this study is no exception. There are substantial disagreements among researchers and clinicians about what constitutes treatment success. In the present instance, treatment was aimed at modifying stuttering behavior, not suppressing it. In addition, a strong emphasis was placed on self-acceptance and adjustment to what is viewed as a chronic disorder. Those goals shape the way in which treatment success is defined and measured. That is clear from the criteria for treatment success used in the present study. For instance, it is possible for some patients in this study to have been rated as highly successful, although their disfluency counts did not change substantially. Certainly not all experts would agree with the premise inherent in this particular treatment model. Systematic investigations of the relationships between ego states, objective measures, and treatment outcome need to be carried out with other treatment populations that are subject to differing treatment approaches and that use different criteria for success.

A further limitation arises from the nature of the ego state constructs and how they are measured. While measures of treatment success showed good reliability (from .59 to .75), as did the objective measures (from .84 to .98), the measures of ego state function did not (from .40 to .61). Measuring ego states in a consistent and reliable way turns out to be a difficult task. For that reason, we are continuing our analysis of ego state function by using measures that are more objective. The idea is to code each statement in each of the subjects' transcripts according to the ego state most closely represented by each statement's syntactic and lexical elements.

Obvious limitations notwithstanding, it is increasingly clear from the present work that a complete model of treatment success in stuttering can not be derived solely from objective measures. Psychodynamic constructs, such as ego states, need to be included to complete the treatment model. At the same time, the training of speech-language pathologists in general and fluency specialists in particular is woefully deficient in teaching the skills needed for counseling and psychotherapy. Moreover, those skills make possible effective psychological intervention that, in our view, is often required for effective stuttering treatment. At the very least, we believe that there is ample evidence here for the need to increase those aspects of the training of our clinical corps.

Acknowledgements

This research was supported, in part, by an RCSA Faculty Grant from the California State University. Sandra Cullinan, Carol A. Murphy, and Vanna Sivilay served as raters for some of the data analyses cited in the present study, and that were reported in a preceding paper.

References

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

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

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

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

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

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

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

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

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

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

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

Change Measures	Words/Min	Total Words	SD Change	ID Change	CB Change
Pre Rx Mean	94.02	187.5	10.79	12.7	3.77
SD	33.61	70.67	8.53	8.77	1.67
Post Rx Mean	110.17	219.4	8.29	5.93	2.16
SD	31.66	60.54	8.29	4.78	1.30
T=	-2.649	-2.629	1.585	4.290	5.362
p	.0126	.0132	.123	< .0002	< .0001

Statistically significant p values are shown in bold face.

Table 2. Means, Standard Deviations, and Significance of Changes of Objective Measures of Stuttering and Speech Rate: Words Per Minute, Total Words, Stuttering Disfluencies (SD), Indeterminate Disfluencies (ID), and Concomitant Behaviors (CB) For High and Low Success Groups

Treatment Group		Words/Min	Total Words	SD Change	ID Change	CB Change
High Success	M	23.6	49.7	-5.12	-8.36	-1.9
(N=21)	SD	37.25	72.77	9.26	10.19	1.91
Low Success	M	2.0	-2.0	2.50	-3.74	-1.05
(N-11)	SD	24.03	46.08	5.78	4.92	1.06
	t=	-1.733	-2.134	2.479	1.736	1.379
	p	.0934	.0411	.019	.1035	.178

Statistically significant p values are shown in bold face.

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

Ego States	Words/Min	Total Words	SD Change	ID Change	CB Change
Adult	.354	.394	.179	.235	.315
Adapted Child	-.396	-.435	-.121	-.030	-.232
Natural Child	.084	.056	-.015	-.054	.186
Nurturing Parent	.287	.299	.115	.101	.011
Critical Parent____	-.025______	.003_______	-.066______	.322________	-185________
Treatment Success	.587	.628	.506	.359	.379

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

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

INDEPENDENT VARIABLE	BETA Coefficient	Constant	R	F Ratio of R
STEP 5
Nurturing Parent	.495168	.775765	.7986	8.6126
Total Words	.00302
Stuttering Disfluencies	.039491
Indeterminate Disfluencies	.039695
Behavioral Concomitants	.202075
STEP 9
Adult	-.243372	.7184432	.8136	4.7868
Adapted Child	-.332662
Natural Child	-.273851
Nurturing Parent	.205564
Critical Parent	-.199486
Total Words	.000498
Stuttering Disfluencies	.050201
Indeterminate Disfluencies	.039335
Behavioral Concomitants	.209854