Учебники / Evaluating Voice Therapy - Measuring the Effectiveness of Treatment Carding 2000

Chapter 6

The future

The need for more controlled studies

In Chapter 2, I discussed the importance of study design in producing robust evidence of treatment effectiveness. It is generally acknowledged that randomised controlled group studies, wherever possible, represent the most powerful method of examining treatment effectiveness. However, this type of study design has rarely been applied to examine voice therapy effectiveness (Wilson et al., 1995).

In Chapter 5, the effectiveness study used a randomized controlled group design to evaluate voice therapy. However, the study was only an evaluation of the efficacy of one therapist’s voice therapy to treat 45 patients. Even though the therapist used a standard set of voice treat­ ment techniques, it may be argued that the study represents evidence of one person’s effectiveness and not voice therapy techniques in general. It may therefore be difficult to generalise the evidence of treatment efficacy to speech/voice therapy practice. The individual qualities of the clinician may be a large potential variable in determining treatment effectiveness. We already know that therapy outcomes can be influenced by the clinician’s attitudes and attributes (Silverman, 1977), by the clinician’s personality characteristics (Combs et al., 1971), and by the nature of the therapeutic relationship (Crane and Cooper, 1983). Systematic evaluation of the influence of clinician-specific variables can be examined only by the publication of a number of similar controlled group studies. One way would be to evaluate the outcomes of a number of voice therapists using the same set of standard techniques. This would enable the examination of the effect of different clinician–patient relationships on therapy outcomes.

97

Determining the effect of therapy contact time

Without a placebo treatment condition, it is difficult to ascertain the effect of therapy contact time in isolation. In other words, one cannot be sure of the effect of regular contact with a professional who is sympathetic to the problem – irrespective of the nature of the intervention. In all of the previ­ ous voice therapy studies discussed in this book, how do we know that the improvement was specifically the result of the treatment and not of other clinician/patient variables? For example, the results of the study in Chapter 5 demonstrated that a combination of direct and indirect therapy contact was more effective than indirect therapy contact alone. However, the study design did not examine the effects of therapy contact time in iso­ lation (i.e. without the therapist engaging in a structured therapy pro­ gramme at all). The effect of a caring and attentive clinician may be as important to the treatment outcome as the therapy programme (Combs et al., 1971). Andrews and Schmidt (1995) state:

Both the clinician and the client are partners in the therapeutic process, and it is the quality of the collaboration rather than the skill of the clinician alone that predisposes a successful outcome. (page 261)

The factors that influence the quality of this therapeutic relationship are not well documented. The ‘attentiveness’ of the clinician (Schmidt and Andrews, 1993; Sorenson, 1992) and his or her ability to be ‘precise, friendly, friendly and dominant’ (Norton, 1983; Schmidt, 1989) may be important variables in treatment outcome. Norton noted that relaxed clinicians are calm and collected, and perceived by patients as being confident and in control. Haynes and Oratio (1978) suggested that the patient’s perception of the clinician’s technical skills and empathic genuineness were most important to clinical effectiveness. Characteristics of the patient that may contribute to clinical effectiveness are even less well understood. Andrews and Schmidt (1995) state:

Despite the undoubted contributions of client characteristics (e.g. person­ ality) to the relational aspects of therapeutic communication, there has been a remarkable dearth of systematic research on the nature and quality of the unique therapeutic relationship forged between each clinician and client. (page 263)

Andrews and Schmidt (1995) attempt to analyse the congruence in personality between clinician and client. They conclude that it was the interaction of clinician/client personality types that was important. Not surprisingly, they also found many permutations of personality factors

carefully the effects of different elements of the therapeutic process in many areas of speech and language therapy:

One of the challenges we face is understanding, describing and detailing components of therapy in order to evaluate the most active and desirable features. (page 166)

How and why a therapy programme is designed in a particular way is based on the therapist’s assessment and perception of what was required in order to make progress. Detailed assessment may identify a small number of core factors, which need to be addressed (Gordon, 1986; Stemple, 1993). However, how these central factors are addressed may vary from patient to patient. As mentioned earlier, one of the most important skills of clinicians is to adapt their behaviour to complement what they perceive as the patients’ needs (Andrews and Schmidt, 1995). How we do this and to what extent are poorly understood. However, it is a subject of considerable interest. A better understanding would not only facilitate more effective therapy (presumably), but also influence the training of clinicians (Schmidt, 1989).

Generally speaking, therapy programmes vary not only in content but also in how they are administered to each individual patient. For example, the decision on how long a patient may stay at any particular stage of the therapy programme is often based on the patient’s vocal performance and how he or she is responding to a particular therapy technique. The judgement about whether to remain and consolidate at a specific stage of a therapy programme or to move on is a matter of clinical judgement. It is likely that the clinician uses a complex series of hypothesis-testing strategies in this decision-making process. However, these aspects of voice therapy dynamics are frequently covert. Further research is required into the nature of these covert processes and how they vary with different types of patients. Enderby and Emmerson (1995) refer to this as ‘describing and disaggregating aspects of therapy’ (page 170). Different starting points and changes in direction in the therapy programme for different people are likely to be the product of a complex therapeutic relationship. Examination of the nature of this relationship and how it influences the course of treatment would be a valuable contribution to the field.

Enhancing treatment effectiveness

Examination of treatment effectiveness is not just a means to an end. The process itself also reveals a number of issues that may further enhance clinical effectiveness. For example, an effectiveness study may show