Finding a Balance
I’m currently a graduate student enrolled in a Stuttering class. We have discussed the importance of treating the person as a whole and helping the client accept his or her stutter. We have also explored therapy techniques that target fluency. I’m curious, what is the balance? Should one aspect be more focused on than the other? I would love to hear the perspective of both SLPs and people who stutter!
Hi,
Rational Emotive Behavior Therapy of Stuttering is based on 1) evolving the beliefs and attitudes about stuttering to more closely resemble reality and help a PWS recover from stuttering, 2) teaching the PWS how to communicate better without excess struggle and forcing, 3) keep the PWS motivated managing his/her emotions and recovery from stuttering, and 4) taking some calculated risks to live life more fully.
As a recovered PWS who works as a clinical psychologist to help other PWS recover from their stuttering, I want to emphasize that all the PWS are idiosyncratic individuals and, thus, the balance for each of them is different.
In general, I start with asking them to make a commitment motivate themselves to recovery by above all recording their feelings and their speech at least once a week.
To encourage them taking positive risks, I ask them to write down three accomplishments and three things that they can be grateful for with each entry in the journal.
I teach them easy Iowa bounces and ask them to overlearn them until they are able to do them in every speaking situation and pre-empt real stutters with an easy bounce.
But the real work is imparting to them helpful beliefs about their stuttering. These include acknowledging stuttering (a form of acceptance) without giving up on getting better at managing unhealthy negative feelings, unhelpful beliefs, and the struggling and forcing of speech. Other helpful and unhelpful beliefs are presented in my paper.
I usually follow the PWS lead on what he or she wants to do, except when they get stuck. Statistically, PWS who spends 70 % time on working on their beliefs recovers the soonest. The rest of the time is divided equally among the three other activities.
Gunars
Dear Maggie,
I am hesitant to say that there is a balance that is right for every client. I find it helpful to learn as much as I can about the client’s perspective on their stuttering, and through these conversations, I learn what is important to them.
Finding out what specific, day-to-day concerns the client has relating to their stuttering will help you plan functional therapy that addresses the changes that the client would like to make. What are the specific situations that cause the client to worry about or leads them to avoid talking? Are they talking as much as they want when they want, or do they reduce the amount of talking they do when they are having a ‘bad’ stuttering day? Are there situations where they would like to engage verbally, but that they avoid due to their stuttering? What do they know about stuttering/the process of producing speech/how stuttering begins/etc? Once you have taken the time to understand the client’s take on their stuttering and the issues around it, you are then ready to help the client collaborate with you to set goals and select specific ways to address the goals.
You note that it is important to help a client accept their stuttering, and I would agree that we do want clients to develop a different relationship with stuttering and communication. However, I avoid talking much about ‘acceptance’, as this is a really loaded term that can mean so many different things. When talking with a client who is very uncomfortable with their stuttering about the need for them to accept it, you may end up driving their true feelings underground. In other words, they may start talking positively about their stuttering because you clearly see this as how they ‘should’ think and talk about their stuttering, whereas deep down they still hate and fear stuttering, and now they feel guilty for having these feelings when they know that they ‘should accept stuttering’. Not a good outcome! “Acceptance” is not something that a person can be talked into. When you truly engage clients in problem solving, rather than ‘teaching’ them what to do, they gain a sense of ownership around managing communication situations. Building confidence and competence is a gradual process. There really is no way to “cheer lead” this into existence. I ask clients to set their own challenges for outside practice. How do I do this? Once we have goals set, I have the client select the skill they wish to practice, where they will do it and how often they will practice between sessions. When they return for the next session, I ask them to describe how their challenge went and, when they have been successful, to tell me very specifically what they did to make that happen. If they did not experience success, we problem solve further, changing the parameters to increase the likelihood of success next time, and move forward with the challenge.
For example, say I am working with a school-age child who sets as a challenge that she wants to answer a question asked by her teacher in class one time each day. At the beginning of our next session, she report that she succeeded. I then ask her to explain how she made this happen, as I want the client to see herself as the agent of change. If she downplays her success by saying, “well, the teacher asked an easy question so it wasn’t very hard to do it”, I might respond with something like, “Remind me what you chose for your challenge”, and she reports, “I was going to answer one question from the teacher every day”. I then might ask, “Did you do that”? When she acknowledges that she did, I might respond, “So you met your goal, correct”? She acknowledges, and I ask her to tell me how she was able to do this. She now tells me, “I told myself in the morning that I understood the math work we are doing and I can share what I know. So when the teacher asked a question, I raised my hand because I knew the answer and I wanted to give it even if I stutter”. I might then put her action into words by saying, “so, you reminded yourself that sharing information with the class is important and something you wanted to do”. Helping clients to own their successes in this way fosters their sense of ability to make the changes that they desire. Does this child now ‘accept’ her stuttering? I don’t know, but I do know that she is making a small choice to communicate whether or not she stutters, so that is a small modification in her thoughts and feelings around her stuttering.
I am not sure whether I addressed your questions about balance, but I hope this give you a bit of insight into what goes into developing a treatment plan that is individualized to a specific client’s needs. Best wishes as you continue your studies!
Regards,
Lynne Shields
Thanks for your insightful question on an important topic. I wish I had a simple answer. “Acceptance” is a fashionable word in the world of stuttering, but it is asked to do a lot of heavy lifting. It means different things to different people. When we use the term, we should know precisely what meaning of “acceptance” we have in mind. Acceptance can be an end in itself, an unconditional positive regard (“I accept my stutter!!”). Acceptance can be a synonym for acknowledgement, an acquiescence to plain facts (“I accept that I stutter”). Or, acceptance can be a means to an end, as in the famous quotation by psychologist Carl Rogers, “the curious paradox is that when I accept myself just as I am, then I change” (“I accept that I stutter, and …”). Whether we, as clinicians, endorse “acceptance (full stop)” or “acceptance (as a means to an end)” for any individual client depends on the perceptions, values, needs, and goals of that individual client at any given time.
As clinicians, we’re only human. We may have strong intuitions and opinions about which version of “acceptance” better serves individuals, or the stuttering community at large. In therapy, however, I do not think we should ever take an ideological approach and automatically steer clients toward one end of the acceptance continuum or another. That is not our role. (We should be treating clients, not training activists). Instead, it is better to (gently) steer clients toward the center, toward acceptance as acknowledgement. Regardless of the treatment approach that is pursued, from avoidance reduction and open stuttering to the strictest fluency shaping, everyone seems to benefit from learning, at one’s own pace, to acknowledge the plain facts of stuttering. Just my opinions! I hope they are helpful. Wishing you the best in your studies and career,
Rob Dellinger
Thanks for your post. It’s hard for me to offer anything in addition to what my colleagues have said so eloquently other than to emphasize again that the balance will be different for every individual. And, some people’s goals may not resonate with a “balance” as we might define it. To me, that is fine. I would not want to take someone who has, say, fluency as a primary goal and try to convince them that they need to be more “balanced” with acceptance. Likewise, I wouldn’t take someone who wanted acceptance above all and try to convince them that they should work on their fluency so they stay in “balance.”
Actually, for me, the concept of balance is over-rated. (I even gave a talk on that at the Australian Speak Easy Association conference last year – *should* we be seeking a balance? I’m not always sure.)
People’s goals are their goals, and whether they match some external definition of balance to me doesn’t seem as important as whether those goals match what they want for their lives. It is not to the clinician to decide.
All that said, I almost always work on multiple goals with adults who stutter – some focus on speech to the extent that the person wants and some focus on attitude to the extent that the person wants and some focus in other areas if that’s appropriate too. I learn about what they want through my comprehensive evaluation that examines more than just observable disfluencies – and, of course, by talking with the client about what he hopes for.
Bottom line for me is that the balance is different for everyone, and our therapy should reflect that.
Thanks again for your post!
J Scott Yaruss