mark irwin therapy reviewed – what works, what didn’t, and why
TRANSCRIPT
MARK IRWIN
Therapy Reviewed – What works, what didn’t , and why
About Stuttering
Research Areas
Speech PathologyGeneticsPsychology/ PsychiatryNeurosciencePharmacology
At this point a video was shown during the congress
In defence of SLPs…
“…no 0ne is Distilling, Integrating and Disseminating relevant research data”. (Bernstein Ratner, Quesal. 2009)
….role of umbrella organisations IFA, ISA,
Which statement(s) is correct?
Research shows that…1. Smooth Speech” (Prolonged Speech) is universally regarded
as the only evidenced based treatment for stuttering.2. All stuttering can be attributed to genes.3. Social Anxiety Disorder (aka Social Phobia) is NOT so
important in stuttering therapy because when fluency is achieved SAD is eliminated.
4. In any case SAD should NOT be diagnosable in PWS since a phobia is an irrational belief and social anxiety is not irrational given the social penalties of stuttering.
5. SAD is not remediable in PWS.6. Two thirds of clients relapse after a speech restructuring
therapy, and SAD does increase likelihood of relapse.
Questions 1: Evidence Base
Evidence Base is.. “an approach to decision making in which the clinician uses the best available evidence in consultation with the patient to decide upon options that suit patient best”. (Gray, 1997. )
Various forms of evidence from ....1. Case reports and patient testimonials (extremely valuable
where cause of disorder unknown BUT…….)2. Randomised Clinical Trials (RCTs BUT……)3. Double Blind RCTs (to check whether it is the treatment
itself that is responsible for success ) (particularly important in childhood stuttering since spontaneous recovery rate is approx 80%)
Question 1: Smooth Speech?
Definition of evidence may priveledge some kinds of treatment over others despite clinician preferences. (Tanenbaum 2005)
…. “no consensus amongst clinicians about what to count or how to count it” (Botterill JFD 2011)
..”absence of Evidence of treatment effectiveness is NOT evidence of absence of treatment effectiveness” (Bloodstein, Bernstein Ratner 2008)
Based on literature review from ‘53 – ’08……….substantial improvements occurs as a result of almost any kind of therapy in 60-80% of cases. (Bloodstein, Bernstein Ratner 2008. A Handbook of Stuttering. 6th ed.)
Question 1 (cont.): Smooth Speech?Other Helpful Treatments
Cognitive Behavioural TherapyRelaxationCounselling or Psychotherapy (eg
neurosemantics )Medical (pharmacological, neurosurgical)Stuttering Modification (plus avoidance
eliminationOther. (Del Farro, Schwartz, McGuire, Dr.
Fluency)
Question 2: Genetic influence 100%?
Dennis Drayna: ISAD Online Conference 2011Twin studies and studies of “inbred” families
indicate that…1. 50-70% of stuttering is genetic2. 30-50% has unknown cause
Of genetic cause 10% due to separate mutations of genes on Chromosomes 12 (Some of rest due to mutations on chromosomes 3 and 6)
(Hereditary DEAFNESS due to mutations in any one of more than 100 genes)
Question 3: SAD is not important?
PWS (arguable the most important stakeholders) frequently report that therapy that addresses cognitive and affective features of stuttering has the most long term benefit to them. (Yaruss et al 2002)
With too much anxiety phobics are unable to think logically. (Lorberbaum et al 2004)
Questions 4 & 5: SAD not relevant?
44% of PWS seeking treatment had social phobia beyond what would be regarded as normal given their dysfluencies. (75% had SAD!!!) (DSM IV ???)(ie SAD not related to frequency/severity of stuttering)(Stein et al 1996)
SAD is remediable form of distress and disability for PWS (Stein 1996, Menzies 2008)
SAD is implicated with personality disorders as being significant factor in relapse from speech restructuring programme. (Iverach 2009)
Question 6: Implication of SAD?
Two thirds of clients relapse after a speech restructuring therapy, and SAD does increase likelihood of relapse.
This is the CORRECT answer.Craig & Hancock (1995), Martin (1981), Iverach et al (2009)
What is Social Anxiety Disorder?
Begins in early childhood.Associated with a genetic predisposition.Sufferers endure significant distress in some or all
social situations. It can be situationally specific.Causes significant impairment to career success,
academic goals and/or general social functioning.Common symptoms include; inability to maintain
eye-contact, erratic breathing patterns, excessive worry and rumination.
CBT Therapy shown to be effective BUT confounded by formation of safety behaviours.
Safety Behaviours
Coping strategies on which a person becomes dependent, thereby restricting therapeutic inquiry and psychological change.
If speech restructuring techniques become safety behaviours, what are the consequences for people who stutter?
Other interesting research
Anterior Cingulate Gyrus (part of limbic system) concerned with…
1. vocalization and emotional and motoric functioning involving the hands 2. regulating autonomic and endocrine activities
(Note link with: Selective Mutism, Shy Bladder Syndrome, Choking aka ‘the Yips’)Therapeutic Alliance.Use of therapeutic methods by SLPs
My View
IF Social Anxiety Disorder in 50-75%THEN there are at least 2 subtypes of
stuttering
THEREFORE…Step 1. Screen for SAD (Liebowitz or SPIN or
?)Step 2. Use clear terminology to differentiate
parts of iceberg (Overt, Covert, SAD, SSS)Step 3. Then do RESEARCH.
