Which SLPs are Effective?

In my last two blog posts I have been talking about how to ensure that your speech therapy program “works”, in other words, how can you be sure that what you do is effecting change in your patient over and above the change that would occur due to maturation and history effects alone? I have suggested that if you choose treatment approaches that have been validated via randomized controlled trials as effective approaches and if you demonstrate that your patient is improving you can be reasonably sure that you are having a positive effect on your patient. I have further cautioned that you need to read the original research carefully and implement the treatment approaches in accordance with the treatment efficacy trials with respect to procedures, treatment intensity and so on in order to ensure that you will get the same effect. These details – the treatment procedures that you decide to implement with your patient – are referred to as the specific ingredients of your treatment program. Throughout my research career I have been focused on the relative efficacy of these specific ingredients – is it effective to use perception training or stimulability training or prepractice with visual cues in comparison to usual care? For example, one-year follow-up of the children treated in Rvachew, Nowak and Cloutier (2004) showed that 50% of the children who received usual care + speech perception training started school with normalized speech versus only 19% of the children who received usual care + dialogic reading. I obviously feel that an important role of the SLP is to know the scientific literature and choose the right specific ingredients for their patients.

In contrast, Ebert and Kohnert (2010) point out that the effectiveness of speech therapy might also be due to “common factors” which include (following Grencavage and Norcross): the patient, the clinician, and the patient-clinician alliance, change processes, and treatment structure. Studies on the effectiveness of teachers and psychotherapists are starting to appear with increasing frequency but I am not aware of any published systematic studies of SLP effectiveness that take a “common factors” approach. Ebert and Kohnert re-analyzed the data from one of my studies (Rvachew and Nowak, 2001, discussed in my previous blog) and concluded that although target selection strategy accounted for a larger proportion of variance in outcomes, individual differences in clinician effectiveness accounted for 20% of variance in outcomes. These researchers surveyed SLPs in Minnesota and asked them to rate various factors for their importance in determining client outcomes. The results showed that SLPs weight client-clinician factors very highly with “rapport” being the item rated as having the greatest impact on therapeutic outcomes. Recently Geraldine Wotton wrote a blog post on the power of the therapeutic relationship that expresses this commonly held view. The thing is however, I knew the SLPs who provided the intervention in Rvachew and Nowak and I can tell you that there were no discernible differences in rapport between these SLPs and their clients. Furthermore, at the time I was the research coordinator for allied health in the hospital and I was responsible for the client satisfaction questionnaire in the hospital. Families reported high levels of satisfaction with their clinicians while reporting varying levels of satisfaction with their child’s outcomes. I was always impressed by the fact that parental satisfaction with their child’s speech outcomes and objective measures of child outcomes were highly correlated (given that I was running several RCTs at the time I could look at this) but uncoupled from uniformly high satisfaction ratings for their relationship with the therapist. I certainly agree that the strong positive relationship between SLPs and their patients is an important factor in treatment efficacy – I just don’t agree that it explains variations in treatment outcomes: think about this carefully – SLPs are selected to have strong interpersonal skills and we are very good at establishing rapport with our patients but we do not all get the same results. There is something else going on here.

Françoise and I recently completed a RCT involving 72 francophone children in which the clinicians were student SLPs from McGill. We have 6 videorecorded therapy sessions for each child, representing more than a dozen student SLPs. Unfortunately we have run out of funds so we haven’t been able to analyze all the video but two students, Amanda Langdon and Hannah Jacobs, obtained summer research bursary funds from the Faculty of Medicine to conduct a pilot project in which they coded the videos for 6 student clinicians, attempting to identify common factors that might differentiate between more and less effective SLPs. In this case the supervising clinical educators told us which student SLPs were more or less effective in their opinion, rating them as “accomplished” or “struggling”. Then Hannah and Amanda coded the videos for factors related to the clinician, the clinician-child alliance and to change processes. Interestingly the factors that differentiated “accomplished” versus “struggling” student SLPs were not those that would be ascribed to the “clinician” category in Glencavage and Norcross’ model. Rather we found large differences in variables that could be categorized as “change processes”. In Glencavage and Norcross’ paper a lot of the factors categorized as change processes are specific to psychotherapy but some are common to speech therapy as well, for example “acquisition and practice of new behaviors”, “provision of a therapeutic rationale”, “naming the problem”, and “contingency management”. Applied to speech therapy we can hypothesize that SLPs may vary in their ability to communicate and/or negotiate the goals of the therapy program to or with the patient, maintain a high response rate during sessions so as to ensure that most of the session is spent practicing new behaviors, and manage contingencies so that the patient is receiving appropriate feedback about their responses during practice. We observed changes in these skills across the six week treatment program for student SLPs who were rated to be “accomplished” or “struggling” by their supervising clinical educators. We found that all the students increased the amount of time devoted to direct therapy in their sessions during the course of their practicum. Accomplished students began with good contingency management skills and improved those skills to an even higher level after six weeks of practice. On the other hand, struggling students began and ended the practicum with poor contingency management skills – in particular these students did not provide appropriate feedback after incorrect responses by their clients. Interestingly, in comparison to struggling students, accomplished students spent more rather than less time in “off task” behavior which may mean that they had more resources available for conversation that served to establish rapport with their clients. Struggling students spent a lot of time “manipulating materials” and therefore their disorganized approach to the therapy sessions may have interfered with the SLP-client alliance. Unfortunately this study is tiny; the coding is hugely time consuming and expensive. However I think that it is crucial for our profession that resources be expended to study these therapeutic processes and the means to improve our students’ skills in learning these skills during their preprofessional practice.

I’d love to hear from student SLPs about your experiences with learning these skills. What do you think your clinical educators could do to help you learn these skills? I’d also love to hear from practicing SLPs – do you agree that skill in the engagement of change processes is an important factor in therapeutic effectiveness? Which change processes do you think are most important in speech therapy?

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4 Comments

  1. Tricia McCabe

     /  May 16, 2013

    Hi Susan, A number of years ago, Alison Ferguson looked at the discourse of student rx sessions – these refs may be useful when you write up the study
    Tricia

    Ferguson Alison Jean, Elliot Ngiare Ronelle, ‘Analysing aphasia treatment sessions’, Clinical Linguistics & Phonetics, 15 229-243 (2001)
    Ferguson Alison Jean, Armstrong Elizabeth, ‘Reflections on speech-language therapists’ talk: implications for clinical practice and education’, International Journal of Language & Communication Disorders, 39 469-477 (2004)

    Reply
    • Thank you Tricia for this interesting resource, there is a lot of interesting material in the IJLCD paper. I also really enjoy Hilary Gardner’s qualitative descriptions of exchanges between SLTs and their child clients and children and their parents whilst engaged in ‘speech homework’. Discourse analysis is a rich source of information about the therapeutic process. Susan

      Gardner, H. (1997). Are your minimal pairs too neat? The dangers of phonemicisation in phonology therapy. European Journal of Disorders of Communication, 32, 167-175.

      Gardner, H. (2005). A comparison of a mother and a therapist working on child speech. In P. a. R. Seedhouse, K. (Ed.), Applying Conversation Analysis. Basingstoke: Palgrave Macmillan.

      Reply
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