About the authors:

Kristen Bragg is currently a second year graduate student working towards her Master’s Degree in Communication Sciences and Disorders at Western Carolina University (Cullowhee, North Carolina, USA).  As a non-traditional, returning student, Kristen left the workforce in 2011 in order to pursue her true passion of helping others to communicate effectively.  She is scheduled to graduate in the spring of 2014 and begin working to complete her Clinical Fellowship. After graduation, she hopes to work with children with a wide range of needs in a school setting.

Perry Fowler is currently a second year graduate student working towards her Master’s Degree in Communication Sciences and Disorders at Western Carolina University (Cullowhee, North Carolina, USA). Previously, Perry studied at the University of Mississippi and received her Bachelor of Science Degree in Communication Sciences and Disorders in 2012. She is currently serving as Vice President of the National Student Speech Language Hearing Association chapter at Western Carolina University. She is scheduled to graduate in the spring of 2014 and begin working to complete her Clinical Fellowship.

David A. Shapiro, Ph.D., CCC-SLP, ASHA Fellow, Board Recognized Fluency Specialist, is the Robert Lee Madison Distinguished Professor of Communication Sciences and Disorders at Western Carolina University (Cullowhee, North Carolina, USA). In his fourth decade of providing clinical services for people who stutter and their families, Dr. Shapiro is a regular presenter at conferences and has taught workshops, provided clinical service, and conducted research in six continents. His book, Stuttering Intervention: A Collaborative Journey to Fluency Freedom, is in its 2nd edition (2011, PRO-ED) and continues to find a wide international audience. Dr. Shapiro is actively involved in the International Fluency Association (IFA) and International Stuttering Association (ISA), received IFA’s 2006 Award of Distinction for Outstanding Clinician in Dublin, Ireland, and was elected IFA President in 2012. He is a person who stutters, has two young adult children with his wife, Kay, and lives near the Great Smoky Mountains National Park.

Stuttering intervention often is distinguished into two general categories – stuttering modification and fluency shaping (Guitar, 1998; Shapiro, 2011). Stuttering modification assumes that stuttering results from struggling with disfluency or avoiding feared words or situations; intervention seeks to reduce speech-related avoidance behaviors, fears, and negative attitudes, while modifying the form of stuttering. In contrast, fluency shaping assumes that stuttering is learned; intervention is based upon principles of behavior modification and seeks to eliminate stuttering in a controlled stimulus environment. In reality, however, most stuttering intervention utilizes a combination of stuttering modification and fluency shaping. This paper addresses an activity called “Catchphrase” that was used as part of a stuttering modification approach with “Jeff,” a school-age boy who stutters. In doing so, we will review characteristics about the case and the activity that led to the expected positive outcomes for Jeff and unexpected outcomes for the clinicians.

In an exemplar form of stuttering modification (Van Riper, 1973), desensitization aims to reduce speech-related anxieties so that the person who stutters can learn new ways of coping with and responding to stuttering. One way to do this is by stuttering deliberately (i.e., pseudostuttering) and then by making modifications in order to stutter more easily or with less effort.  By pseudostuttering, the person’s awareness of fluency and disfluency increases, as does facility to control stuttering. But how can a clinician who has never stuttered understand the nature of stuttering and help a person who stutters become comfortable with the risk of fluency failure and the use of fluency controls? Manning (2004) posed this question directly for clinicians who do not stutter: “How can you understand stuttering? You don’t stutter!” (p. 58). This very thought is what prompted us – two clinicians who do not stutter (Bragg and Fowler) – to modify the popular game “Catchphrase” for the client to practice desensitization and for the clinicians to learn to pseudostutter. Though we prepared for a fun activity, we could not have been prepared for its impact on our client and, particularly, on us both personally and professionally.

Case Description

Our client, Jeff, was a 13-year old boy who, at the time, had been receiving fluency intervention services for two years. He had experienced significant progress by increasing his use of speech in social situations where he previously elected not to speak, and heightening his overall fluency in conversation by 17%. However, his use of fluency controls had reached a plateau in therapy. We were unsure of how to continue with therapy and even if it should be continued. The dilemma was that although Jeff had a significant number of observable disfluencies, he perceived himself as fluent. It was unclear whether Jeff was unaware, in denial, or apathetic. He was proud of his personal success since the start of therapy and received an immense amount of positive reinforcement from his family, friends, and clinicians. However, there was plenty of work still to be done in order to take fluency to the next level and to eventually work on stabilization, two objectives he indicated a desire to achieve.

The Clinical Activity

To help bring Jeff’s fluency to this next level, we knew that we needed to determine his awareness of fluency and his ability to distinguish it from disfluency. We decided the best way to do this was by creating a fun activity that included pseudostuttering. Since it is never fun to play a game by oneself, we decided that we must play by the same rules as the client and pseudostutter ourselves.

The rules of Catchphrase are simple yet difficult to follow under pressure. First, the players divide into two teams. One player at a time is provided a word and must describe it to the teammates without saying the word itself. The team receives a point when the fellow teammates correctly guess the word being described. We adapted the game and made a set of cards with our own words that were tailored to the client’s age and interests. The electronic version of Catchphrase has a beeping timer. We chose not to use a timer during therapy because it would create unnecessary pressure for the speaker. Rather, we added another element to the activity for usefulness in the clinic setting.

Specifically, we created a set of cards that directed each player to speak in a specific manner. These cards included: using fluency controls; speaking quietly, loudly, quickly, or slowly; stuttering with whole word repetitions, part-word repetitions, or phrase repetitions; or using prolongations, interjections, or revisions. During the game, which consisted of the client, two clinicians (Bragg and Fowler), and one clinical supervisor (Shapiro), each player was required to abide by the speech pattern specified on the card that was drawn. The prescribed speech pattern was required not only during the game, but also during related conversation that involved asking game-related questions, relaying how one felt, or making general comments to other players. For accountability purposes, each person started with the same number of tokens. All players rewarded the others with a token for speaking in the manner as directed by his or her card; all players removed a token from a player for failing to speak as directed by the card. The token system reminded all players at some point to “get back on track,” as it was easy to forget to stick to the directive on the card, especially if the card represented a novel way of speaking as it did for the clinicians.

Outcomes

First and foremost, Catchphrase provided Jeff with a heightened understanding and a sense of control and empowerment. After we reviewed what each card meant and provided examples, Jeff was eager to play. By chance, he first drew many cards directing him to stutter. When he finally drew a card directing him to use fluency controls, his overall fluency improved tremendously compared to previous sessions and the beginning of the present session. Before the Catchphrase activity, he demonstrated one or more disfluency on 18% of the words spoken during a two minute conversational sample. During the activity, he used his controls and demonstrated disfluency on less than 5% of the words spoken in a conversational sample of the same length. We used an audio recorder to play back Jeff’s use of fluency controls to further heighten his awareness and to offer positive feedback.

Catchphrase indeed was beneficial for the client. However, what we did not expect was the positive impact it had on both of us as clinicians. Although we knew that we would be stepping outside of our comfort zone to participate in a new experience, we couldn’t have known that we would be affected in the manner and to the degree that we were. When the game first started, we were more focused on how to stutter as directed by the card. With practice, however, throughout the two-hour session, stuttering almost became second nature. We were so dedicated to playing the game and trying to understand what it means to stutter that, at one point, we transcended the game and felt as if we were people who stutter. It is difficult to describe, but all people in the room, including our client and supervisor, realized what was happening and the significance of it. Both clinicians experienced moments of genuine embarrassment and frustration. Our own speech is something we never had actually thought about previously. One of us (Bragg) tried to make a joke and it took so long to get to the punch line that the joke was abandoned. One of us (Fowler) lost her train of thought when explaining directions for the next part of the game. We were so focused on how to speak that we forgot our place in the narrative. The demand created by speaking in a prescribed manner seemed to overwhelm our capacity to keep up with what was needed to be said. By the end of the session, we yawned incessantly due to interrupted breathing and our eyes watered from fatigue. When we tried to speak in our usually fluent voices, we continued to stutter on occasional words and experienced generalized speech disruption. Experiencing genuine disfluency for the first time and the related speech effort simply exhausted, if not humiliated, us. At the end of the session, we felt like we would rather not speak than go through all of the tedious effort it took to communicate. We had heard people who stutter explain this before, but we had never actually experienced it. As we expressed to Jeff and Dr. Shapiro at the time, “We knew this activity of pseudostuttering would be difficult, but never imagined that it would impact us both physically and emotionally.” In response, Jeff said, “Welcome to my world. Now you know what I’ve been going through. You’ve been stuttering for a few minutes, but try stuttering your whole life.”

Discussion

Though we may never fully know what it is like to be a person who stutters, this activity gave us a glimpse into that reality. It brought us to the empathic “as if,” shortening the distance between our reality and that of the people we serve (Rogers, 1961; Shapiro, 2011). If anything, our empathy is stronger and we feel more prepared to work with and learn from people who stutter. It is our recommendation that speech-language pathologists who intend to work with people who stutter engage in pseudostuttering multiple times and in multiple settings to gain insight into the reality of stuttering. Our client related more closely with us in this session than in others, perhaps because he felt that we were beginning to understand his experience. He could see that we put ourselves into his experience, that we genuinely wanted to know more. He saw the impact that stuttering had on us. As clinicians, we learned more during this activity than we ever expected. We found the experience to be enjoyable and rewarding, in addition to being memorable, humbling, and inspiring.

Closing

Challenging experiences raise questions. We are considering many; we invite you to join us as we ponder the experience of stuttering:

• Do clinicians who stutter make better clinicians for people who stutter? Can a clinician who does not stutter work effectively with a person who stutters?
• Do people who stutter understand the experience of another person who stutters better than a person who does not stutter? Do clinicians who stutter have biases or predispositions that can interfere with or reduce the objectivity of the clinical process for a person who stutters?
• Can anyone ever truly understand the experience of another person? What facilitates and what inhibits a person’s understanding of another person’s experience?
• This paper addressed one activity – Catchphrase – that remarkably enhanced two clinicians’ understanding of stuttering. What other activities might help clinicians build their own understanding of stuttering and the uniqueness of the stuttering experience to each individual?
• What opportunities presently exist for student clinicians in professional preparation to understand the experience of stuttering? How might the graduate experience be enhanced to achieve such an understanding in order to deliver best practice for people who stutter and their families?

References

Guitar, B. (1998). Stuttering: An integrated approach to it nature and treatment (2^nd ed.). Baltimore: Lippincott/Williams & Wilkins.

Manning, W. H. (2004, Spring). How can you understand stuttering? You don’t stutter! Contemporary Issues in Communication Sciences and Disorders, 31, 58-68.

Rogers, C. R. (1961). On becoming a person. Boston, MA: Houghton Mifflin.

Shapiro, D.A. (2011). Stuttering intervention: A collaborative journey to fluency freedom (2^nd ed.). Austin, TX: PRO-ED.

Van Riper, C. (1973). The treatment of stuttering. Englewood Cliffs, NJ: Prentice Hall.