About the Authors

Loryn McGill is a speech-language pathologist who specializes in treating people who stutter in her private practice. She is a member of faculty at Chapman University in Orange, California, where she is Professor of Fluency Disorders.  She has presented at the California Speech and Hearing Association (CSHA), FRIENDS and the National Stuttering Association (NSA).  She has developed and hosted CEU courses as well as annual one-day conferences.  Loryn has been involved with research, examining the use of medical intervention in stuttering and is currently involved in international research examining intervention in young children who stutter. You can learn more about her practice at www.OCfluency.com and contact her at 2900 Bristol St. B 103, Costa Mesa, CA 92626, USA. Phone: (949) 302-5681; E-Mail: lorynmcgill@gmail.com

Nora A. O’Connor is a licensed clinical social worker and a person who stutters living in Los Angeles, California.  Nora facilitates counseling groups, in her private practice, for kids, teens and adults who stutter.  Nora treats the emotional response to stuttering.  She is on staff at the Successful Stuttering Management Program providing Cognitive Behavioral Treatment and Mindfulness.  She is in the process of developing a CBT and Mindfulness workbook for SLP and PWS.  Nora has been involved locally and nationally with stuttering self help organizations for almost 20 years. She is featured in two stuttering documentaries, Spit It Out (2004) and Right Here, Right Now (PBS, 2000).  She is an adviser to StutterTalk and author of the chapter Substance Abuse and Stuttering in the book Stuttering: Inspiring Stories and Professional Wisdom.  She holds additional training in addiction studies, trauma interventions, motivational engagement and walk & talk therapy.  You can learn more about her practice at www.NoraOConnorLCSW.com and contact her at 566 S. San Vicente, Suite 102, Los Angeles, CA 90048-4622, USA.  Phone: (011) 310-736-8623; E-Mail: NOConnorLCSW@gmail.com

Empowering a person who stutters (PWS) to advocate for themselves and explore self-determination are of interest for both Speech-Language Pathologist (SLP) and Licensed Clinical Social Workers (LCSW). Both groups of clinicians can learn how to help without hindering in their respective roles. The purpose of this paper is to explore self-advocacy from the perspective of an SLP and LCSW as they collaborate to achieve this goal with PWS. We will discuss self-advocacy within the dynamic transition from a therapy room to the day-to-day life; the role of community support, increasing a client’s self-esteem and helping without hindering. We will present literature review on self-advocacy. Lastly we will discuss tips and tools for SLPs and LCSWs

Introduction:

It is no surprise that when a person who stutters self-advocates an increase in communication is related to confident attitudes, high-self-esteem and better social skills. An individual willingness and desire to communicate is a critical predictor of positive peer relations and acceptance (Richmond & McCroskey, 1998). It is critical that clinician’s should, “help the child find a balance between modifying speech on the one hand and developing and maintaining healthier attitudes and feelings on the other” (Chmela & Reardon, 2001, p.1).

“Through the therapy process, the child will be faced with difficult situations.  The clinician can assist the child in dealing more effectively with problem situations by helping him develop problem-solving skills. Learning how to problem solve speaking situations will empower the child and help him see that he has communication choices “ (Walton, 2013, p. 117). The present state of stuttering therapy programs enables the clinician to render many PWS virtually stutter-free in the clinic. A major clinical problem, however, is the transfer of fluency to non-clinical situations and its maintenance over time (Altholz & Golensky, 2004). Learning self-advocacy skills within the therapy setting with structured practice outside the clinic will assist with long-term generalization and maintenance. “ There is an element of risk as well as the possibility of partial or complete failure.  In order to consider such challenges, we must reach some level of self-esteem and security” (Manning, 2001, p. 142). By directly addressing self-advocacy skills as part of a treatment plan for therapy, clinicians are better preparing their clients for long-term management of their stuttering.

Therapy Room:

Both the speech therapy room and the counseling room create a safe place for clients to increase vulnerability, learn new skills and develop self-esteem. The goal is to create safety in other areas of the client’s life and to transition and normalize the use of new skills. The therapy environment is frequently limiting, and fluency is often developed quickly. In the counseling office, a client can often master cognitive behavioral skills and anxiety management skills quickly. In both therapy settings, treatment goals are needed to the transfer of skills outside of therapy room, as well as introduce more real life situations to create the opportunity for greater success. An SLP and LCSW treating the same client together can develop a comprehensive plan to achieve the stated goals.

Introduction of challenging situations along a hierarchy is imperative to mastering higher-level skills of independence. Early in their treatment, the client determines the challenges, from mild to intense, they wish to undertake and in doing so, set their own goals. Situations may range from being able to talk with a neighbor over the fence, to speaking in large group situations

A LCSW would introduce Cognitive Behavior Therapy (CBT) skills, Mindfulness and Grounding skills. CBT skills you learn to, “change the way you think, the way you behave and the way you feel” (Burns, 1990, p. 5). Mindfulness skills guide you to be present in the moment to participate fully in life. Grounding is a set of strategies to detach from emotional pain, (i.e. racing thoughts, negative talk, worries, anger, and sadness), (Najavitis, 2002, p. 130-135). The LCSW would use ‘walk and talk therapy’ to practice skills outside of the therapy room.

A client would utilize these skills when practicing phone calls in speech therapy room or asking a question to a cashier clerk. With the hierarchy in place the client will understand how utilizing these coping skills will aid in increased self esteem to advocate for themselves. A client would be encouraged to analyze what it means to be a person who stutters and how that impacts successful communication.

Community Supports:

The clients’ immediate surroundings and support may send a conflicting message as the client takes more risk with their communication and deals with the emotions created by the challenging situations. This begins with communicating with the PWS that they are okay, even if they stutter. That what they have to say is worth listening to despite the fact that the words may not come out fluent. Shifting the focus in the clients’ immediate environment from focusing on fluent words to the content of the message is the shift that must take place to promote self-advocacy.

Finding a balance between doing and supporting can be challenging within a family or community unit. Watching a child or adult struggle to produce a sound, while people stare in confusion, can lead to a loved one having feelings of wanting to rescue. When the client’s self-confidence increases and they know that they are okay even if they stutter, they can better navigate these situations without rescue, and family members can also begin to relax. This will enhance the client’s success.

Self Esteem:

One of the ways to increase self-confidence is to allow the client to take chances. This starts in the controlled environment of the therapy or counseling room and gradually moves to situations that the client has determined to be of higher risk. Clients will typically take risks as they establish trust with the SLP or LCSW and feel that they are being helped and not hindered. Guiding a client to be prepared for setbacks allows “failures” to be learning experiences.

SLPs can prepare clients by doing speaking situation activities in the office (i.e. telephone calls).  Watching an SLP do tasks first can increase a client’s willingness to try. A client can choose how they want the therapist to voluntarily stutter and what they should say. This can be done through role-play in and out of the therapy room, then with trusted individuals, and then the actual trial situation. Prior to the actual task, the client can make predictions as to how the situation may go, and then discuss prediction vs. reality after the situation. Specific fluency strategies are discussed as well as how to react if asked to repeat a certain word or phrase. Whether to advertise, or mention stuttering, would be determined prior to engagement. A school or work presentation on stuttering would be an option to increase self-esteem through educating peers.

An LCSW will model positive affirmations in front of a mirror and then have the PWS do the same. A Daily Mood Log is taught to identify negative feelings, automatic thoughts and cognitive distortions (Burns, 1999 pg. 75). Grounding exercises and mindfulness techniques are led by an LCSW during the session, and then will be set up for PWS to do on their own. Client’s reality testing is measured by a “Prediction vs. Reality” worksheet to explore assumptions held before situation, and then discusses what actually happened afterwards. Lastly, Dr. Breitenfedlt explains in the Successful Stuttering Management Workbook, “Advertising is the most important technique that a stutterer can learn.” (Breitenfeldt & Lorenz, 1999, p.26). Advertising or being open about stuttering will most likely increase self-esteem and plays a role in self advocacy.

Helping Without Hindering:

SLP:  Parents in particular will ask what to do if their child is stuttering. First, the home environment has to evoke support for communication. Second, the child has to believe that they are good communicators. Third, trust between the child and the parent needs to be strong enough that the child feels that the parent believes they can communicate. That being said, the child needs to know they can turn to the parent when they are really struggling and ask for help without solely relying on the parent (i.e. on a particularly rough day). If the child is continually looking for the parent to speak for them it is because they do not believe they are able to communicate effectively. The parent needs to assist in increasing the child’s self-esteem by increasing praise.

LCSW: In order to help and not hinder, do not make assumptions. Ask clients what they need.  At times, the client may not be interested in self-advocacy or increasing self-esteem, instead their goal is to be fluent. Or other times they want to reduce anxiety and let a few people know they stutter. Therapy begins where the client is at – honor the client’s journey, establish achievable goals and treatment plan. Treatment plans will be updated often to reflect current needs.

Self-Advocacy Tips and Tools:

SLP:  So much is lost when one is not able to speak. The long-term effect on an individual who is not able to communicate in risky situations is damaging. When you ask a person who stutters, “ How would your life be different if you did not stutter?” you get a wide range of responses. For some people the answer is that it would not be all that different, just easier to talk. For others they may have chosen completely different career paths, had different personal relationships and overall feel that they would be happier. That the life they currently have does not resemble the life they feel they would have if they did not stutter. For those individuals the risk was always too high and the chance of stuttering was always too great to do the things that they wanted. So often in therapy the primary focus is on fluency. When the shift is made away from the fluency of a word to the value of a message then the client will gain the confidence they need to speak on their own behalf. This being said, it cannot be done unless the client is systematically introduced to more challenging situations as their skills increase and they are participating in well structured avoidance reduction therapy.

LCSW: When you get the opportunity to work with a PWS you may have much to learn. Most often the client will be your best resource about his or her own stuttering. You must also be willing to learn more on your own. Begin by contacting the Stuttering Foundation of America, National Stuttering Association or Friends to obtain educational material. You may learn of a local workshop or a support group that’s near you and decide to attend. You may consider reading memoirs such as “Out with It: How Stuttering Helped Me Find My Voice” by Katherine Preston (2013), Stuttering: A Life Bound up in Words by Marty Jezer (1997) or Voices: A Stutterers Odyssey, by Scott Damian (2013). You may view a movie discussing stuttering such as, The King’s Speech and Rocket Science. You can subscribe to StutterTalk Podcast, and browse the archives for interesting topics.

Conclusion:

Joseph Sheehan’s “Giant in Chains” complex discusses the stuttering puzzle of “if only he did not stutter, then there could be no limit to his accomplishments.” (Sheehan, 2013, p. 33). What we have discussed is how a PWS can be successful while stuttering with support from an SLP, and/or LCSW and the community. As a PWS learns to advocate and develop self-esteem it is hoped that they will believe that there is no limit to their accomplishments, even when they stutter. In this paper, we have explored what both a SLP and a LCSW are doing together to help the PWS to advocate for themselves and increase their self-esteem. We have discussed our personal and professional experiences that demonstrate a variety of approaches to guide people who stutter into a lifestyle of self-advocacy and self-confidence.

References

Altholz, S. & Golensky, M. (2004). Counseling, support, and advocacy for clients who stutter. Health & Social Work 29.3.

Burns, D. (1999). The Feeling Good Handbook, (2^nd ed.) (p. 5, 75).  New York, NY: Penguin Group.

Breitenfeldt, D., & Lorenz, D. (1999), Successful Stuttering Management Program ( Second Edition, p. 26). Cheney, WA.

Chmela, K., & Reardon, N. (2001). The School-Age Child Who Stutters: Working Effectively with Attitudes and Emotions (p.1). Memphis, TN, Stuttering Foundation of America. & Reardon, N. (200. Memphis, TN: Stuttering Foundation of America

Manning, W. (2001) Clinical Decision Making in Fluency Disorders (2^nd ed.) (p. 142). San Diego, CA: Singular.

Najavatis, L. (2002).  Detaching from Emotional Pain (Grounding). In H. T. Blane and T. R. Kosten (Eds), Seeking Safety: A Treatment for PTSD and Substance Abuse (First Edition, p. 130-135) New York, NY, The Guilford Press.

Richmond, V. P., & McCroskey, J. C. (1998). Communication: Apprehension, Avoidance, and Effectiveness, 5th edition. Needham Heights, MA: Allyn and Bacon.

Sheehan, J. (2013). Stuttering Foundation of America, Effective Counseling in Stuttering Therapy, Publication No. 0018 (3^rd Printing)(p.33) , Memphis, TN: Stuttering Foundation of America.

Walton, P. (2013). Fun with Fluency for the School-Age Child (p. 117) Austin, TX: PRO-ED.