Ego-States and Measures of Fluency:
Unraveling Connections to Treatment Outcome
William S. ROSENTHAL1, Shannon N.
AUSTERMANN HULA2 and Liz RUD3
1Department of Communicative Sciences and Disorders
California State University, East Bay,
william.rosenthal@csueastbay.edu
2San Diego
State University / University of California, San Diego Joint Doctoral
Program in Language and Communicative Disorders, San Diego, California, 92182,
USA
3Livermore Valley Joint
Unified School District,
Abstract. Previous computational analysis showed that changes in
ego-states occur during stuttering therapy, and that these changes are related
to treatment outcome. The current study
extends that investigation by examining the relationship of changes in
ego-states, as defined by transactional analysis theory, to changes in fluency
rate, types of dysfluencies, concomitant behaviors, and ratings of the success
achieved by participants. Regression analysis shows that treatment outcome is
significantly related (R=.79) to both ego-state change and change in objective
speech measures. A complete understanding of the treatment process must include
both psychodynamic constructs and objective measures.
1. Introduction
One
of the persistent threads in stuttering research is whether treatment success
is measured sufficiently by counts of fluency breaks, or whether success is
better determined by changes in social and psychological constructs that are
reflected by such things as increased speech output, increased social
interaction, and greater self acceptance. This controversy has been well
represented by Yaruss (2001). He suggests that we usually measure treatment
based on changes in the production of speech disfluencies. Many treatment
approaches, however, address other aspects of stuttering, including the
speaker's reactions to stuttering and the overall effect on the speaker's
ability to communicate. The issue is further complicated by the belief that
so-called objective speech measures are somehow more valid and more reliable.
However, problems with the reliability and validity of these kinds of
measurement have been noted (Cordes and Ingham, 1994). Furthermore, the
most widely used clinical measure of stuttering, the Stuttering Severity
Instrument (SSI-3) (Riley, 1994), has been shown to have questionable rater
reliability (Lewis, 1995). While advocates of each point of view may feel
passionate about their position, the truth lies with the results of empirical
investigation. The purpose of the present research is to help unscramble this
puzzle.
Previous
work presented the theoretical relationship between life scripts, ego-states,
and stuttering, supported mainly by case studies (Rosenthal, 1997, 1998). In
that earlier work, a preliminary, single case study was done that compared pre
and post therapy transcripts of a successful treatment outcome. The analysis
showed an increase in information content statements from 19 in the pre-therapy
text to 24 in the post-therapy text, or an increase of 26%. At the same time,
statements reflecting emotional content comprised 21-26% of the pre-therapy
text, but only 4-8% of the post-therapy text. The reduction in emotional
content reflects a reduction of statements made from child ego state, and an
increase in factual information produced by the adult ego state. The difference
in these two texts is even more dramatic when one views the actual video
recording. The changes in ego state, from pre-therapy to post-therapy, were
clearly evident in the participant’s posture and facial expression.
A
broader study that included data from 31 adults showed significant changes in
ego-state over the course of successful stuttering therapy (Rosenthal, 2001).
The results of that study, however, showed that only slightly more than 32% of
the variance associated with treatment success was accounted for by changes in ego
states. The question remained, then, as to what is the relative association
between treatment outcome and changes in ego states when compared with changes
in objective measures of speech behavior.
The present research systematically extended the latter investigation by
including objective measures of treatment outcome. Furthermore, it compared the
association of ego-state change and objective speech measures with an
independent measure of treatment outcome, thus allowing for an estimate of the
contribution of each of those constructs.
2. Method
Archival
data were used that had been collected over 40 years ago as part of another
research project (Naylor & Rosenthal, 1968). In that project, samples of speech were
collected from 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. The collection of this material is described in
greater detail in an earlier paper (Rosenthal, 2001).
2.1 Participants
The
participants for this study were 32 young adult stutterers on active duty in
military service, and who were enrolled in an eight-week, intensive in-patient
treatment program. There were 31 males and one female. The ages of the
participants in the original study (Naylor & Rosenthal, 1968) ranged from
18 to 35 with a mean age of 24 years. Each participant was recorded under
several controlled speaking conditions at the beginning and at the conclusion
of the therapy program. The conditions included one minute of reading, two
minutes of spontaneous speech, and a one-minute telephone call.
The
program was based on a modification approach similar to that described by Van
Riper (1973) and currently used by the Successful Stuttering Management Program
(SSMP) (Breitenfeld & Lorenz, 1989; De-Nil, Kroll, & Ham, 1996). SSMP
is an intensive residential treatment program that follows Van Riper’s approach
and emphasizes acceptance, desensitization, elimination of avoidance, and
modification of stuttering behaviors directed towards easier speech. Treatment
is conducted in individual and group sessions, and in the community.
2.2 Treatment Success
Separate
clinical ratings were made of the success of each participant 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 participant 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.
For
this phase of the study, the 64 speech segments were arranged sequentially, so
that the pre therapy segments occurred first and post therapy segments occurred
second for each of the participants. Three raters evaluated each of the
segments, the author and two graduate students in speech-language pathology.
These graduate students (PWS) had participated in treatment programs similar to
the one described in this study. Ratings were made of each segment immediately
after viewing
2.3 Ego-State Analysis
The
premise, supported by previous work (Rosenthal, 2001), is that changes in the
predominant 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.
Each
participant's ego state strength 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 constructs of ego states specific to
transactional analysis have been measured using graphic representations called
egograms (Dusay, 1972) and questionnaires (Loffredo, Harrington, & Okech, 2002). Construct validity has
been established by Loffredo,
Harrington, and Okech (2002) and Loffredo, Harrington, Munoz, and
Knowles (2004). Because the present study utilized archival data, and since the
original participants were not available, egogram constructs were used rather
than questionnaires.
Ego
state ratings were made by the author and another speech-language pathologist,
who was familiar with ego state identification and who was experienced in
applying the theory and technique of transactional analysis in the treatment of
speech disorders. For this phase of the study, the 64 segments were arranged in
a pseudo random order, so that the pre therapy segments occurred first for half
of the participants, and post therapy segments occurred first for the other
half. Pre and post therapy segments for a given participant were separated by
placing at least four segments of other participants in between. Only the
spontaneous speech segments were presented. The segments were viewed without
sound, so that ratings would not be influenced by comments from the
participants about the success or failure of their therapy experience.
Therefore, ego state ratings were based on non-verbal information only, mainly
facial expressions, gestures, and body posture. The relative strength of each
ego state, Adult, Adapted Child, Natural Child, Critical Parent, and Nurturing
Parent, was assessed and assigned a score that totaled 20 points for all ego
states combined.
2.4 Objective Measures
Objective
measures of fluency rate, types of disfluency, and concomitant behaviors were
obtained using an adaptation of the Stuttering Severity Instrument (SSI)
(Riley, 1994). For the current study, Stuttering Disfluency (SD) was defined as part word repetitions, sound and syllable
repetitions at the beginning of words, audible prolongations, inaudible blockages,
and cessations of phonation. A
separate category of Indeterminate Disfluency (ID) was established. This category included whole word repetitions (mono and polysyllabic), phrase repetitions,
interjections, extraneous words, filled pauses, and stereotyped starters. 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
spontaneous speech samples.
Two
raters, trained by the senior author, completed the objective counts from the
tapes and transcripts of each participant. Both were graduate students in
speech-language pathology and had completed an academic course in fluency
disorders. These raters did not rate any other behaviors associated with the
study. Discrepancies between raters were resolved so as to achieve a 90% level
of agreement.
3.0 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?
3.1 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 Disfluency
(ID) and Concomitant Behaviors (CB) decreased significantly over the course of
treatment. Although Stuttering Disfluency (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.
Table 1. --Pre- and Post-Treatment Means
of Various Objective Measures of Stuttering and Speech Rate: Words Per Minute,
Total Words, Stuttering Disfluency (SD), Indeterminate Disfluency (ID), and
Concomitant Behaviors (CB)
(Statistically significant p values are shown in
bold face)
|
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 |
3.2 Changes Related to Treatment Success
For
these analyses, the experimental group was divided into two subgroups, High Success
(N=21) and Low Success (N=11), based on change scores and following the
procedures described in previous work (Rosenthal, 2001). This measure was the
difference between pre and post therapy ratings of the features and criteria
listed above (2.2). The Low Success group comprised of subjects whose change
scores were 1 or less (Mean = .52), and a High Success group comprised of
subjects whose change scores were greater than 1 (Mean = 2.49). 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 Disfluency. 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.
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 Disfluency
(ID), and Concomitant Behaviors (CB)For High and Low Success Groups
(Statistically significant p values are shown
in bold face)
|
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 |
.
3.3 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 low-moderate positive correlation between measures of verbal output
and increased Adult Ego State. Conversely, there is a low-moderate negative
correlation between measures of verbal output (Words/Min and Total Words) 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, low-moderate to moderately-high positive correlations were found between
all objective measures and the independent measure of treatment success (see
Table 3).
While
measures such as treatment success showed decent rater 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). In this study, at least, the lack of
agreement between raters of ego state measures reduced the likelihood of
showing a robust relationship between ego state change and other variables.
Table 3. --Correlation (r) Between Ego States, Treatment Success
and Various Objective Measures of Stuttering and Speech Rate: Words Per Minute,
Total Words, Stuttering Disfluency (SD), Indeterminate Disfluency (ID), and
Concomitant Behaviors (CB)
(Statistically significant r-values (p< .05) are
shown in bold face)
|
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 |
3.4 Predictive Model
A
previous study (Rosenthal, 2001) 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.
For
the present study, a similar analysis was conducted to examine the predictive
relationship of objective measures on treatment outcome. That analysis showed
that the variables Total Words, Stuttering Disfluency, Indeterminate
Disfluency, and Concomitant Behaviors resulted in a multiple R of .71,
accounting for nearly 50% of the variance attributable to treatment outcome.
Finally,
all variables were regressed (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%.
Table 4. --Stepwise Linear Multiple
Regression with Treatment Outcome as the Dependent Variable with Steps 5 and 9
Shown.
|
INDEPENDENT VARIABLE |
BETA Coefficient |
Constant |
R |
F Ratio of R |
|
STEP 5 |
|
|
|
|
|
Nurturing Parent |
.495168 |
.775765 |
.7986 |
8.6126 |
|
Total Words |
.00302 |
|
|
|
|
Stuttering Disfluency |
.039491 |
|
|
|
|
Indeterminate Disfluency |
.039695 |
|
|
|
|
Behavioral Concomitants |
.202075 |
|
|
|
|
|
|
|
|
|
|
STEP 9 |
|
|
|
|
|
Adult |
-.243372 |
.7184432 |
.8136 |
4.7868 |
|
Adapted Child |
-.332662 |
|
|
|
|
Natural Child |
-.273851 |
|
|
|
|
Nurturing Parent |
.205564 |
|
|
|
|
Critical Parent |
-.199486 |
|
|
|
|
Total Words |
.000498 |
|
|
|
|
Stuttering Disfluency |
.050201 |
|
|
|
|
Indeterminate Disfluency |
.039335 |
|
|
|
|
Behavioral Concomitants |
.209854 |
|
|
|
4.0 Discussion
The
purpose of this and a previous study (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 relationship
was 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.
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 alternative 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
as did the objective measures, the measures of ego state function did not.
Measuring ego states in a consistent and reliable way turns out to be a difficult
task.
Kerlinger
(1979) has warned against the notion that research design is synonymous with
research methodology, and that merely gathering data constitutes research.
Sometimes, however, the researcher is faced with the choice of either abandoning
a line of investigation that would be prohibitive in time and cost, or
proceeding with known limitations.
Although such studies may be flawed, they may still yield some useful
albeit limited information. The reader will appreciate that the purpose of the
present research was not to establish either the effectiveness or the
sustainability of a particular treatment approach. Rather, it was to determine
the relative contributions of objective measures of fluency on the one hand,
and psychodynamic measures exemplified by ego states on the other, to measures
of change over the course of treatment. Still, the absence of a control group,
or wait interval, mitigates the degree to which the findings may be
generalized. The data were collected, however, within a consistent framework of
archival records from a single participant pool. Furthermore, the raters of the
various segments of the study were largely insulated from one another. While it
is not possible to assert with authority that the changes observed were
attributable to the particular treatment method used, the fact is that some
participants changed more than others, and the relationship of the collected
measures to those changes is of interest.
The
stated limitations notwithstanding, the present work suggests 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 typical training
of speech-language pathologists in general and fluency specialists in
particular is 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.
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Acknowledgements
This
research was supported, in part, by an RCSA Faculty Grant from the California
State University. Sandra Cullinan, Carol A. Murphy, and Vanna Sivilay Nicks served
as raters for some of the data analyses cited in the present study, and that
were reported in a preceding paper. Some of the data in this report were first
presented at the Annual Convention of the American Speech-Language-Hearing
Association, November 2001,