About the authors: Lourdes Ramos-Heinrichs, MA, CCC-SLP, BCS-F. Lourdes works full time in the Boston Public Schools as a Spanish-English bilingual speech-language therapist. She is a Board Certified Specialist in Fluency Disorders.  Throughout her career, she has published and presented nationally and internationally on topics related to fluency and fluency disorders.  In 2014, She chaired an ASHA Coordinating Committee Project Team on Reading Fluency and co-authored various presentations and papers based on this research project. She regularly mentors SLPs who wish to obtain their specialty recognition in fluency disorders. Lourdes coaches and mentors her fellow SLPs in the Boston Public Schools and in local universities, counseling them on best practices on clinically servicing children who stutter. In her role as fluency mentor in the Boston public schools, she has opportunities to observe children who stutter across the school district, facilitate best assessment/therapy outcomes, and influence administrative decisions that impact children who stutter. She is looking forward to a future partnership with stuttering organizations in Mexico, her country of origin.

About the authors: Sandra Garzon, MA, CCC-SLP, BCS-F. Sandra is a bilingual speech-language pathologist and a Board Certified Specialist in Fluency Disorders.  She has worked in the Boston Public Schools for the last 25 years and specializes in dual language learners in the preschool and school age populations. Sandra is a member of the American Speech and Hearing Association (ASHA), Division 4 (Fluency and Fluency Disorders), Division 11 (Administration and Supervision), and is also a member of International Fluency Disorders Association (IFA). She is trained in Parent Child Interaction (PCI) at the Michael Palin Center in London and Solution Focused Brief Therapy (SFBT) at Boston University.  Sandra counsels and treats parents and families of at-risk preschool children from culturally and linguistically diverse backgrounds. She continues to deepen her understanding of bilingual stuttering treatment. Sandra enjoys traveling with her family particularly to her native Colombia.

The BSR is a clinical tool that promotes pride, respect and dignity among persons who stutter in treatment.  The scale enables the client to communicate cognitive and emotional reactions to the stuttering, as these can be elusive and difficult to verbalize.   Being able to identify, rate, and express struggles with communication empowers the client; even small positive changes in how life is approached can be recognized and celebrated.  The idea is to support the client in developing self-awareness, compassion, and kindness toward the self.  Rather than professing to know all the answers, clinicians promote self-discovery by recognizing that solutions to problems lie within.  Professionals need to validate the stuttering experience by providing a means for the client to talk about it openly, document it, rate the severity on a scale, and systematically reflect on it during therapy sessions.  Through the self-report process, clients connect with their own stuttering experience and take an active role in making the journey of healing a dignified one.

Bilingual Self-Report for Persons Who Stutter (BSR)

Auto-Reporte de la Tartamudez Bilingüe

The BSR is a bilingual, English/Spanish, Likert scale that allows SLPs to informally measure changes in their clients’ emotional and cognitive reactions to stuttering.  The scale is written both in English and Spanish to allow Spanish-speaking clients to participate in the self-report process.  The BSR can be reviewed with the client at each session to ensure that updated information is driving therapy programming.  Client responses to the questionnaire can help the therapist to understand if treatment is producing desired outcomes in terms of carryover from the clinical setting to the natural environment; and any reported positive changes from session to session serve to motivate the client to continue or intensify efforts to reach fluency goals. If a client reports no changes or notes a decrease in fluent behaviors such as increased social avoidances, the SLP can promptly reprioritize treatment goals.  Thus, the client’s reported changes, or lack thereof, in this questionnaire can be used to guide direction or pace of treatment, and to guide relevant topics of clinical conversation from session to session.

There are a few scales on the market that aim to elicit detailed information from persons who stutter about their own views, perceptions and feelings about their personal experience of stuttering (Clinical Use of Self-Reports in SSI-4, 2009; Camperdown Program, 2016).  The BSR elicits responses from the client that can be looked at quickly to inform the SLP of emotional/cognitive struggles that need immediate attention and the BSR can be paired with other treatment programs to allow the therapist a glimpse of how the client is responding to treatment.  For more detailed analysis of emotional and cognitive struggles, the OASES can be used to perform an extensive overall assessment of the speaker’s experience of stuttering (Yaruss and Quesal, 2006).

The BSR is a three-page scale that assists in data collection for understanding the client’s current communication needs and emotional/cognitive responses to stuttering moments. Due to the complexities of the stuttering experience, the client may struggle to unpack thoughts, feelings and emotions that may be causing roadblocks in the recovery of fluent speech (e.g., “I worry excessively about how I say things”).  It is not uncommon for SLPs to follow generic therapy programs that are purchased commercially.  Although extensive research and thought have been invested in the creation of commercially available programs, the therapist must remain flexible in the application of such programs and be ready to revise treatment goals based on information provided by the use of self-reports.

The use of self-report effectively assists clients to communicate their speech difficulties and fluency concerns in precise language.   Random communication exchanges in the clinical setting can result in frustration and poor client-clinician relationship.  To exemplify an ineffective clinical scenario, the following dialogue looks at a verbal interaction that may occur between a clinician and a client: the clinician asks, “So how is it going?”, and client responds, “It’s going good.”.  This dialogue may be followed by the therapist saying: “Good job!”, and then, without further exploration of responses to treatment, transitioning into fluency targets such as slow-speech or other verbal skill that may be useful to achieve fluency within the clinic but results in poor carry-over into the natural environment.  In this mock clinical dialogue, the opportunity to gain powerful information from the client that can be used as raw material to optimize best clinical outcome is lost through the unstructured exchange.

The SLP can promote, through systematically collected data, the practice of self-reflection on how beliefs, attitudes and feelings affect progress towards desired outcomes.  In our own clinical practice, BSR information has been used to guide the client in the development of a constructive view of the self as a dignified person with great talents and a unique personality. We believe the most valuable outcome of any stuttering treatment program is the emergence of self-acceptance, confidence, and self-advocacy.  It has been a fulfilling experience to see our own clients become more confident as they take ownership of their own recovery.  Initially they may be surprised to learn that fluent speech occupies only a small piece of the treatment program, but soon they realize the value of cultivating positive attitudes and warm feelings toward oneself.  In our experience, many clients initially need a lot of encouragement to increase tolerance and acceptance about their stuttered speech; and it helps to expose them, early in the treatment, to famous people who stutter that have overcome their speech challenges and have gone on to achieve at a high level (e.g., Vice President Joe Biden).

The BSR Likert scale reveals the intensity of each emotional/cognitive reaction that impacts the client’s ability to communicate.  It prompts the client to report on the following aspects of the stuttering-experience: (a) perception of the speech difficulty, (b) efforts/avoidances, and (c) beliefs/attitudes and feelings about the communicative concern.

Data collected from the BSR allows the SLP and client to improve communication about communicative struggles, feelings and avoidances.   Information from the self-report helps the SLP to make informed clinical decisions and to be better able to shape desired behaviors through validation of even small changes in therapy outcomes.  The client should be empowered to take ownership of his/her own stuttering experience.

The BSR helps to de-emphasize stutter-free speech as the ultimate goal in stuttering treatment.  The aim of stuttering therapy is for clients to regain positive perceptions about their speech, to effectively manage their feelings, attitudes, and beliefs and to reduce social avoidances. Persistent thoughts, feelings of unworthiness, and punitive internal monologue (e.g., “I’m incompetent.”) adversely impact recovery from stuttering. A positive indicator of success in therapy manifests when the client expresses a sense of freedom from emotional struggles, demonstrates relief from shame, and begins to participate fully in life.

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References

Camperdown Program. (2016) Australian Stuttering Research Center. http://sydney.edu.au/health-sciences/asrc/clinic/adolescents/camperdown.shtml

SSI-4: Stuttering Severity Instrument – Fourth Edition. (2009)  Pro-ed.  An International Publisher.

Yaruss, J. S. and Quesal, R. W. (2006) Overall Assessment of the Speaker’s Experience of Stuttering (OASES): Documenting Multiple Outcomes in Stuttering Treatment. Journal of Fluency Disorders, 31, 90-115.