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  • Lanza et al: Zantac v. Prevacid v. placebo in double blind study treatment of ulcers; improvement measured by physical change of endoscopy; after 2 weeks 1/3 of placebo patients healed; after 4 weeks just under half healed; 2/3 of Zantac and 88% of Prevacid had healed ulcers Braithwaite & Cooper: 835 women in headache study 4 groups who normally treat selves with aspirin Completely blinded study Participants told that 2 well known on market aspirins were being compared for effectiveness Group A—placebo labeled analgesics Group B-same placebo with brand name of most popular aspirin in UK (much advertising) Group C-aspirin labeled analgesic tablets Group D-aspirin with same labeling as Group B Aspirin did work better than placebo and worked better with a brand name on it Branded placebos reported more pain relief in an hour than placebos labeled analgesic Graceley et. al: 4 possible treatments administered to wisdom tooth patients for pain: placebo, something which might increase pain or do nothing, a drug which might reduce pain, or no treatment. Clinicians told 1 st week drug to reduce pain not available, 2 nd week it was available, so patients might get this pain reliever. Pain significantly less in 2 nd group of placebo patients vs. first group of placebo after 60 minutes. Clinicians conveyed to patients might receive a powerful painkiller Uhlenhuth et. al: mild tranquilizer study in treating anxious outpatients at 3 clinics; tranquilizer more effective than placebo in 1/3 clinics only when physicians adopted very enthusiastic attitude about drug; when experimental attitude toward drug was adopted, no difference in outcome b/t drug and placebo groups, and both groups did worse than with enthusiastic physician Benson & McCallie: review of angina literature: drugs found to be 70-90% effective in 1940s and 1950s before there were double blind trials; then subjected to placebo controlled trials—70-90% effectiveness reduced to 30-40%
  • PPT

    1. 1. The “Meaning Response” as Applied to Stuttering Therapy John A. Tetnowski, Ph.D., CCC-SLP, BRS/M-FD Kathleen Scaler Scott, M.S., CCC-SLP, BRS/M-FD Jack S. Damico, Ph.D., CCC-SLP, BRS/M-FD University of Louisiana at Lafayette
    2. 2. The history behind this project… A little bit of magic fairy dust?
    3. 3. The impact of meaning upon stuttering therapy success <ul><li>What is truly meant by the placebo effect? </li></ul><ul><li>What is the meaning response? </li></ul><ul><li>What studies support the meaning response? </li></ul><ul><li>How does knowing this help us to plan treatment? </li></ul><ul><li>How does knowing this help us to plan future research? </li></ul>
    4. 4. The placebo effect…reinterpreted (Moerman, 2002) <ul><li>Originally understood as changes produced by an inert therapeutic condition, i.e. a placebo </li></ul><ul><li>Conflict in definition because placebos are inert </li></ul><ul><li>If something is inert, it causes no change or effect </li></ul><ul><li>But yet placebos are said to cause a change or effect </li></ul>
    5. 5. The meaning response (Moerman, 2002) <ul><li>“ Psychological and physiological effects of meaning in the treatment of illness” (Moerman, p. 14) </li></ul><ul><li>Positive effects include most of the things known as the placebo effect ; negative effects include most of the things known as the nocebo effect (both are meaning based) </li></ul><ul><li>It also includes things that are not traditionally part of the placebo effect (active vs. inert meds) </li></ul>
    6. 6. Studies Supporting the Meaning Response <ul><li>Meaning response results from interaction with a perceived healing context </li></ul><ul><ul><li>Physical changes (Lanza, Goff, Scowcroft, Jennings, & Greski-Rose, 1994) </li></ul></ul><ul><ul><li>Brand name has an effect upon pain reduction of aspirin and placebo (Braithwaite & Cooper, 1981) </li></ul></ul><ul><ul><li>What doctors know makes a difference ( Gracely, Dubner, Deeter, & Wolskee, 1985 ) </li></ul></ul><ul><ul><li>How strongly doctors believe in the effectiveness of treatments makes a difference (Uhlenhuth et. al, 1966) </li></ul></ul><ul><ul><li>“ Skeptics can heal 30% to 40% of their patients with inert medication, while enthusiasts can heal 70% to 90%” (Benson & McCallie, 1979) </li></ul></ul>
    7. 7. Studies Supporting the Meaning Response <ul><ul><li>Form of treatment has an impact upon healing </li></ul></ul><ul><ul><ul><li>Color pill and its intended purpose (Blackwell, Bloomfield & Buncher, 1972) </li></ul></ul></ul><ul><ul><ul><li>Number of pills (Blackwell, Bloomfield & Buncher, 1972) </li></ul></ul></ul><ul><ul><ul><li>Pill vs. Shot in U.S. (de Craen, Tijssen, de Gans, & Kleijnen, 2000)—in Europe less of an effect </li></ul></ul></ul><ul><ul><ul><li>Surgery works even if not real (Thomsen, Bretlau, Tos, & Johnson, 1981) </li></ul></ul></ul><ul><ul><ul><li>Placebo has an effect upon pain reduction only if patient knows it’s happening (Benedetti, 1996) </li></ul></ul></ul><ul><ul><ul><li>Response varies with culture (Lock, 1986) </li></ul></ul></ul>
    8. 8. Current Trends in the field of Stuttering… <ul><li>Client-centered focus (Rogers, 1946) </li></ul><ul><ul><li>Clinician involvement in self-help groups (Reeves, 2006; Yaruss et al., 2002) </li></ul></ul><ul><ul><li>Clients as “consumers” (Reeves, 2006; Yaruss & Quesal, 2004a; Yaruss & Quesal, 2004b) </li></ul></ul><ul><ul><li>Consumer role on advisory boards and credentialing organizations </li></ul></ul><ul><ul><li>Call for research partnership between clinicians, researchers, consumers (Yaruss & Quesal, 2004a; Yaruss & Reeves, 2002; Yaruss et al., 2001 ) </li></ul></ul>
    9. 9. Current Trends in the field of Stuttering… <ul><li>Consumer needs haven’t changed, but our response to them has… </li></ul><ul><ul><li>Changes in what researchers are willing to study </li></ul></ul><ul><ul><li>Health insurance payments for alternative approaches (Cleary-Guida, Okvat, Oz, & Ting, 2001) </li></ul></ul><ul><ul><li>Client perspective studies on recovery (Finn, 1996; Finn, Howard & Kubala, 2005), treatment (Plexico, Manning & DiLollo, 2005), role of support groups (Trichon, 2006; Yaruss et al., 2002) </li></ul></ul>
    10. 10. Current Trends in the field of Stuttering… <ul><li>Multifactorial theory of stuttering and implications for treatment ( Smith, 1999; Smith & Kelly, 1997) </li></ul><ul><li>What works for a client </li></ul><ul><ul><li>One therapy? </li></ul></ul><ul><ul><li>Combinations of therapy? </li></ul></ul><ul><li>Depends upon what each means for a client </li></ul>
    11. 11. To understand what’s meaningful to a client… <ul><li>Constructivism: Meaning shaped by the interaction of language and experience in client’s life (Vygotsky 1934, 1986) </li></ul><ul><li>Meaning is socially constructed (Berger & Luckman, 1966) </li></ul><ul><ul><li>Lock (1986) </li></ul></ul><ul><ul><li>de Craen et al. (2000) </li></ul></ul>
    12. 12. To understand what’s meaningful to a client… <ul><li>What’s meaningful for a CLIENT and for an SLP in terms of therapy is initially shaped by: </li></ul><ul><ul><li>Culture (home environment, education system) </li></ul></ul><ul><ul><li>Background </li></ul></ul><ul><ul><li>Experiences </li></ul></ul><ul><li>And is further shaped by: </li></ul><ul><ul><li>Experiences (Kamhi, 1994) </li></ul></ul><ul><ul><li>Interactions with others (Yaruss & Quesal, 2004a) </li></ul></ul><ul><li>An SLP example… </li></ul>
    13. 13. So what does this say about therapy? <ul><li>Skeptics and how we present approach really matters (Lidcombe & Speecheasy examples) </li></ul><ul><li>Form of treatment may make a difference </li></ul><ul><ul><li>High technology vs. low technology </li></ul></ul><ul><ul><li>Ongoing vs. intensive </li></ul></ul><ul><ul><li>Individual vs. group </li></ul></ul>
    14. 14. So what does this say about therapy? <ul><li>Who administers the treatment may make a difference…but it all depends upon the consumer’s perspective of each scenario </li></ul><ul><ul><li>Specialist vs. non-specialist </li></ul></ul><ul><ul><li>Master’s vs. Ph.D. </li></ul></ul><ul><ul><li>New clinician vs. experienced clinician </li></ul></ul><ul><ul><li>Person who stutters or not </li></ul></ul><ul><li>A client example </li></ul>
    15. 15. Clinician-Client Congruence (Manning, 1999): Am I aware of what my belief system is? <ul><li>“ Maybe rather than asking which treatment strategy is best, we should be asking the infinitely more complex question of why a particular strategy or technique might be best for a certain clinician, for a particular client, at a specific time” (Manning, p. 128) </li></ul><ul><ul><li>Increased progress when patient and doctor are in agreement (Starfield et. al, 1981) </li></ul></ul><ul><li>Congruence leads to comfort </li></ul><ul><li>Comfort leads to confidence </li></ul>
    16. 16. What about the “true believer”? <ul><li>Role of clinician confidence and the meaning response </li></ul><ul><ul><li>How strongly doctors believe in the effectiveness of treatments makes a difference (Uhlenhuth et al., 1966) </li></ul></ul><ul><ul><li>“ Skeptics can heal 30% to 40% of their patients with inert medication, while enthusiasts can heal 70% to 90%” (Benson & McCallie, 1979) </li></ul></ul><ul><ul><li>Kamhi (1994) </li></ul></ul><ul><ul><li>“ Being a true believer allows you not to ‘slip into the tentacles of relativism’, but needs to be flexible to realize that there may be more than one way to teach something” (p. 197) </li></ul></ul>
    17. 17. Within confidence lies our socially constructed view of effectiveness… <ul><li>What does effectiveness mean to you as a clinician? </li></ul><ul><ul><li>Elimination of stuttering? </li></ul></ul><ul><ul><li>Communicating without avoidance? </li></ul></ul><ul><li>If you witness success through an approach that is not congruent with yours, what are you left feeling skeptical about? </li></ul>
    18. 18. Within confidence lies our socially constructed view of effectiveness… <ul><ul><li>If our approach is not congruent with our definition of success, it becomes difficult to exude the level of confidence necessary to evoke the meaning response in our clients. </li></ul></ul><ul><ul><li>If you use and are confident in a singular approach, this may not be an issue. </li></ul></ul><ul><ul><li>If you are focused on client-centered therapy, you must have confidence in the client’s ability to drive the therapy and the approaches to a certain extent. (A real life example) </li></ul></ul>
    19. 19. An approach to therapy vs. a therapy approach…
    20. 20. Strupp (1986)… Four Elements to Effective Psychotherapeutic Process <ul><li>Guided by a theory </li></ul><ul><li>Therapist creates and maintains interpersonal context </li></ul><ul><li>Therapist seeks to understand meaning behind client’s behavior </li></ul><ul><li>Therapist attempts to reformulate meaning in a way for client to use it productively </li></ul>
    21. 21. What does this look like? <ul><li>Narrative therapy (Neimeyer, 1995) </li></ul><ul><li>Cognitive restructuring </li></ul><ul><li>Fluency Shaping approach </li></ul><ul><li>Stuttering Modification approach </li></ul><ul><li>The Lidcombe Program (Onslow & Packman, 1999) </li></ul>
    22. 22. - X - X X Reformulate Meaning - X - X X Understand Meaning X X ? X X Interpersonal X X X X X Theory Lidcombe Stuttering Modification Fluency Shaping Cognitive Restructuring Narrative Therapy
    23. 23. So what does this say about therapy? <ul><li>Perhaps any approach will work if it is grounded in theory </li></ul><ul><li>But we must consider the meaning of it for the client, because this is the bottom line </li></ul><ul><ul><li>If fluency shaping means to a client, “I should avoid stuttering at all costs”, avoidances may remain </li></ul></ul><ul><ul><li>If stuttering modification means to a client, “I can never have complete fluency”, motivation may decrease (ex. with adolescents) </li></ul></ul>
    24. 24. So what does this say about therapy? <ul><li>Your confidence in the method and your expression of this confidence can have a significant impact upon progress (this may be a case for specialist vs. non-specialist) </li></ul><ul><li>If you must project confidence and believe in some theory, then you need congruence between therapist and approach </li></ul>
    25. 25. So what does this say about therapy? <ul><li>The meaning response is triggered by what the client values—this should help guide your choice of approach (Seligman, 1995) </li></ul><ul><li>Brand names, such as specialists, may make a difference just from perception </li></ul><ul><li>Putting someone on a waiting list and giving them suggestions is in fact some type of meaning-based treatment—this has significant implication for spontaneous recovery rates of preschoolers </li></ul>
    26. 26. So what does this say about therapy? <ul><li>Form of treatment may make a difference </li></ul><ul><ul><li>Length of Therapy </li></ul></ul><ul><ul><li>Number of sessions per week </li></ul></ul><ul><ul><li>Meaning of form will tend to vary by culture </li></ul></ul>
    27. 27. So what does this say about therapy? <ul><li>Grounding in a theory is important, but what theory is less important </li></ul><ul><li>Experience may be less important if other components are there—however, experience may bring things like grounding in theory </li></ul>
    28. 28. So what do I do Monday morning with my clients? <ul><li>Know your paradigm and be flexible within it </li></ul><ul><li>Ground your approach in theory—not trial and error </li></ul><ul><li>Use an approach you can justify and have confidence in </li></ul><ul><li>Project your confidence in the approach </li></ul><ul><li>Be there with your clients—listen and understand their needs </li></ul>
    29. 29. So what do I do Monday morning with my clients? <ul><li>If you are a skeptic about the approach the client wants, you may want to consider sending them to someone else…but on the other hand…if you are flexible within your paradigm, this can work if you can… </li></ul><ul><li>Be flexible and move your ego out of the way </li></ul>
    30. 30. So how do we establish meaning? <ul><li>Have client journal things like… </li></ul><ul><ul><li>What do you think the reasoning is behind what you’re working on in therapy? </li></ul></ul><ul><ul><li>What lesson/message do you take away from the activities we’re working on? </li></ul></ul><ul><ul><li>What does fluency mean to you? </li></ul></ul><ul><ul><li>What does stuttering mean to you? </li></ul></ul><ul><ul><li>What are your perceptions of your fluency skills? </li></ul></ul>
    31. 31. How about research? <ul><li>We need to look at the meaning effect closely and examine its impact upon stuttering therapy outcomes </li></ul><ul><li>Compare the psychotherapy research with that of stuttering therapy, following the methods of Strupp (1986) </li></ul><ul><ul><li>Ethnographic interviews with successful therapists from all paradigms to find out the basic principles they follow in therapy </li></ul></ul>
    32. 32. References <ul><li>Benedetti, F. (1996). The opposite effects of the opiate antagonist Naloxone and the cholecystokinin antagonist Proglumide on Placebo analgesia. Pain, 64 , no. 3: 535-543. </li></ul><ul><li>Benson, H., & McCallie, D. P. (1979). Angina pectoris and the placebo effect. New England Journal of Medicine, 300 , no. 25: 1424-1429. </li></ul><ul><li>Blackwell, B., Bloomfield, S. S., & Buncher, C. R. (1972). Demonstration to medical students of placebo responses and non-drug factors. Lancet, 1 , no. 763: 1279-1282. </li></ul><ul><li>Braithewaite, A., & Cooper, P. (1981). Analgesic effects of branding in treatment of headaches. British Medical Journal (Clinical Research Ed.), 282 , no. 6276: 1576-1578. </li></ul><ul><li>Cleary-Guida, M.B., Okvat, H. A., Oz, M. C., and Ting, W. (2001). A Regional Survey of Health </li></ul><ul><li>Insurance Coverage for Complementary and Alternative Medicine: Current Status and Future Ramifications. The Journal of Alternative and Complementary Medicine, 7 (3), 269-273. </li></ul>
    33. 33. References <ul><li>deCraen, A. J., Tijssen, A. G., de Gans, J. and Kleijnen, J. (2000). Placebo effect in the acute </li></ul><ul><li>treatment of migraine: Subcutaneous placebos are better than oral placebos. Journal of </li></ul><ul><li>Neurology, 247 (3), 183-188. </li></ul><ul><li>DiLollo, A., Neimeyer, R. A., and Manning, W. H. (2002). A personal construct psychology view </li></ul><ul><li> of relapse: Indications for a narrative therapy component to stuttering treatment. Journal of </li></ul><ul><li>Fluency Disorders, 27 , 19-42. </li></ul><ul><li>Finn, P. (1996). Establishing the validity of recovery from stuttering without formal treatment. </li></ul><ul><li>Journal of Speech and Hearing Research, 39, 1171-11. </li></ul><ul><li>Finn, P. , Howard, R. and Kubala, R. (2005). Unassisted recovery from stuttering: Self- </li></ul><ul><li>perceptions of current speech behavior, attitudes, and feelings. Journal of Fluency </li></ul><ul><li>Disorders ,  30 ( 4), 281-305 . </li></ul><ul><li>Gracely, R. H., Dubner, R., Deeter, W. R., and Wolskee, P. J. (1985). Clinicians’ expectations influence placebo analgesia. Lancet , 1, no. 8419: 43. </li></ul><ul><li>Kamhi, A.G. (1994). Research to Practice: Toward a Theory of Clinical Expertise in </li></ul><ul><li>Speech-Language Pathology. Language, Speech, and Hearing Services in the Schools, </li></ul><ul><li> 25 , 115-118. </li></ul>
    34. 34. References <ul><li>Lanza, F., Goff, J., Scowcroft, C., Jennings, D., and Greski-Rose, P. (1994). Double-blind comparison of Lansoprazole, Ranitidine, and Placebo in the treatment of acute duodenal ulcer. Lansoprazole study group. American Journal of Gastroenterology, 89 , no. 8: 1191-1200. </li></ul><ul><li>Lock, Margaret M. (1986b). Introduction to anthropological approaches to menopause. Culture, </li></ul><ul><li> Medicine and Psychiatry, 10, 1-7. </li></ul><ul><li>Manning, W.H.. (1999). Progress Under the Surface and Over Time. In Bernstein Ratner, </li></ul><ul><li> N. & Healey, E.C. (Eds.), Stuttering Research and Practice. Mahwah, NJ: Lawrence </li></ul><ul><li>Erlbaum Associates. </li></ul><ul><li>Moerman, D. (2002). Meaning, medicine and the ‘placebo effect.’ New York, NY: </li></ul><ul><li>Cambridge University Press. </li></ul><ul><li>Onslow, M. and Packman, A. (1999). The Lidcombe Program of Early Stuttering Intervention. In </li></ul><ul><li>Bernstein Ratner, N. & Healey, E.C. (Eds.), Stuttering Research and Practice. Mahwah, NJ: </li></ul><ul><li>Lawrence Erlbaum Associates. </li></ul><ul><li>Plexico, L., Manning, W.H. and DiLollo, A. (2005). A phenomenological understanding of </li></ul><ul><li> successful stuttering management. Journal of Fluency Disorders, 30 , 1-22. </li></ul><ul><li>Reeves, L.(2006). The role of self-help/mutual aid in addressing the needs of individuals who </li></ul><ul><li>stutter. In Bernstein Ratner, N. & Tetnowski, J.A. (Eds.). Current Issues in Stuttering Research </li></ul><ul><li>and Practice. Mahwah, NJ: Lawrence Erlbaum Associates. </li></ul><ul><li>Seligman, M.E.P. (1995). The Effectiveness of Psychotherapy: The Consumer Reports </li></ul><ul><li>Study. American Psychologist, 50(12), 965-974. </li></ul>
    35. 35. References <ul><li>Smith, A. (1999). Stuttering: A unified approach to a multifactorial, dynamic disorder. In </li></ul><ul><li>Bernstein Ratner, N. & Healey, E.C. (Eds.), Stuttering Research and Practice. Mahwah, NJ: </li></ul><ul><li>Lawrence Erlbaum Associates. </li></ul><ul><li>Smith, A., and Kelly, E. (1997). Stuttering: A dynamic, multifactorial model. In R.F. Curlee & </li></ul><ul><li>G.M. Siegel (Eds.), Nature and treatment of stuttering.: New directions (2nd ed., pp 204-217). </li></ul><ul><li>Needham Heights, MD: Allyn & Bacon. </li></ul><ul><li>Starfield, B., Wray, C., Hess, K., Gross, R., Birk, P. S., and D’Lugoff, B. C. (1981). The influence of patient-practitioner agreement on outcome of care. American Journal of Public Health, 71, no. 2: 127-131. </li></ul><ul><li>Strupp, H.H. (1986). The nonspecific hypothesis of therapeutic effectiveness: A current </li></ul><ul><li> assessment. American Journal of Orthopsychiatry, 56(4), 513-520. </li></ul><ul><li>Strupp, H. H. and Hadley, S. W. (1979). Specific vs. nonspecific factors in psychotherapy: A </li></ul><ul><li> controlled study of outcome. Archives of General Psychiatry, 36 (10), 1125-1136. </li></ul><ul><li>Thomsen, J., Bretlau, P., Tos, M., and Johnsen, N. J. (1981). Placebo effect in surgery for Meniere’s Disease. A Double-blind, placebo-controlled study on Endolymphatic Sac Shunt Surgery. Archives of Otolayrngology, 107 , no. 5: 271-277. </li></ul><ul><li>Trichon, M. (2006). Getting the maximum benefits from support groups: Perspectives of </li></ul><ul><li> members and group leaders. Perspectives on Fluency and Fluency Disorders, 17 (1), 10-13. </li></ul><ul><li>Uhlenhuth, E. H., Rickels, K., Fisher, S., Parks, L. C., Lipman, R. S., and Mock, J. (1966). Drug, </li></ul><ul><li> doctor’s verbal attitude and clinic setting in symptomatic response to pharmacotherapy. </li></ul><ul><li>Psychopharmacology, 9, 392-418. </li></ul>
    36. 36. References <ul><li>Vygotsky, L. (1986). Thought and Language. (A. Kozulin, Trans.) Cambridge, MA: MIT Press. </li></ul><ul><li>Yaruss, J.S., and Quesal, R.W. (2004a). Partnerships between clinicians, researchers, and people </li></ul><ul><li>who stutter in the evaluation of stuttering treatment outcomes. Stammering Research, 1, 1-15 . </li></ul><ul><li>Yaruss, J.S., and Quesal, R.W. (2004b). Response to Commentaries: The best way for clinicians to </li></ul><ul><li> learn what their clients want from treatment is to ask them what they want from treatment. </li></ul><ul><li>Stammering Research, 1, 28-30 . </li></ul><ul><li>Yaruss, J.S., Quesal, R.W., Reeves, L., Molt, L., Kluetz, B., Caruso, A.J., Lewis, F. and McClure, </li></ul><ul><li>J.A. (2002). Speech treatment and support group experiences of people who participate in the </li></ul><ul><li>National Stuttering Association . Journal of Fluency Disorders, 27, 115-135. </li></ul><ul><li>Yaruss, J.S., Quesal, R.W., Tellis, C., Molt, L., Reeves, L., Caruso, A.J., McClure, J. and Lewis, F. </li></ul><ul><li>(2001). The impact of stuttering on people attending a National Stuttering Association </li></ul><ul><li>convention. In H-G Bosshardt, J.S. Yaruss, & H.F.M. Peters (Eds.), Fluency disorders: Theory, </li></ul><ul><li>research, treatment, and self-help (proceedings of the Third World Congress on Fluency </li></ul><ul><li>Disorders; pp. 232-236). Nijmegen, The Netherlands: Nijmegen University Press. </li></ul><ul><li>Yaruss, J.S., and Reeves, L. (2002). Pioneering stuttering in the 21st century: The first joint </li></ul><ul><li>symposium for scientists and consumers (Summary Report and Proceedings). Anaheim, CA: </li></ul><ul><li>National Stuttering Asssociation. </li></ul>
    37. 37. Questions? [email_address] [email_address] [email_address]