About the author: David A. Shapiro, Ph.D., CCC/Speech-Language Pathology, is a Fellow of the American Speech-Language-Hearing Association, a Board Certified Specialist in Fluency and Fluency Disorders, and the Robert Lee Madison Distinguished Professor at Western Carolina University (Cullowhee, North Carolina, USA). For 39 years, Dr. Shapiro has taught workshops and presented papers, provided clinical service, and conducted research on six continents. His book, Stuttering Intervention: A Collaborative Journey to Fluency Freedom (2nd ed., 2011, PRO-ED, www.proedinc.com) 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 Award of Distinction for Outstanding Clinician, and served as IFA’s President from 2012-2014. Most recently, Dr. Shapiro received the 2016 Oliver Max Gardner Award, the University of North Carolina Board of Governors’ highest honor for faculty in its 17-campus system. Dr. Shapiro is a person who stutters, has two adult children with his wife, Kay, and lives near the Great Smoky Mountains National Park.

Workers in every phase of the helping professions recognize that the client-clinician relationship is a, if not the, crucial variable in the treatment process. (Emerick & Hood, 1974, p. vii)

Methods and materials used in therapy remain insignificant until touched by a spark, the individual clinician’s uniqueness, which elevates them beyond the commonplace. (A. T. Murphy, 1974, p. 30)

The objective of supervision is to develop independent professionals who can provide optimal services to individuals who have communication disorders. (Anderson, 1988, p. 12)

This paper acknowledges the shortcomings in preparing speech-language pathologists (i.e., clinicians, SLPs) to work with people who stutter (i.e., clients, PWS), reviews an experience of clinical service and professional preparation at a university setting during fall 2015 and spring 2016 that brought about client and clinician success, and presents candid reactions and insights from both teens and young adults who stutter and the graduate student clinicians who treated them. Those reactions reveal the respect, dignity, and recognition – indeed the pride – of and by each other and demonstrate how each contributed to each other’s understanding of stuttering and the uniqueness of the stuttering experience.

An Ideal Objective

At the heart of the clinical process are universal stories of human challenge yielding to human triumph. Pursuing fluency freedom provides PWS and their clinicians an opportunity to learn and grow together. Fluency freedom enables PWS of all ages and abilities to consider avenues that heretofore were unimaginable. This is the end goal.

Reality

Recurring observations indicate that SLPs have little experience interacting with PWS, feel inadequately prepared for stuttering treatment, hold negative attitudes toward stuttering and PWS, and experience discomfort anticipating such clinical interactions (Bloodstein & Bernstein Ratner, 2008; Cooper & Cooper, 1985, 1996; Guitar, 2014; Manning, 2010; Tellis, Bressler, & Emerick, 2008). Not surprisingly, PWS occasionally indicate that SLPs fail to understand the feelings and personal experiences of their clients and are not aware of their own negative attitudes toward PWS (Corcoran & Stewart, 1998; Shapiro, 2011; St. Louis, 2001). Making matters even more challenging, changes in the American Speech-Language-Hearing Association’s (ASHA’s) requirements for professional preparation rendered greater flexibility for universities to design their academic and clinical curricula. In practice, however, some programs cut back on coursework and clinical training in fluency disorders, a designation erroneously referred to as “low incidence.” Thankfully, positive changes are occurring today as opportunities for professional preparation of student clinicians and continuing education for SLPs have significantly expanded.

Clinical service and professional preparation can be integrated, enabling student clinicians and their clients each to achieve the end goal. As stated, sharing such an example is the purpose of this paper, leading to a series of questions for related discussion.

The Clients’ Experience: Combining Self-Help and Modified Direct Treatment

Self-help, advocacy, support, or mutual aid groups for diverse concerns have been organized for many years. The earliest self-help groups began among ethnic communities in the USA in the mid-1800s. The first nationally recognized self-help group for PWS was the Council of Adult Stutterers, formed in 1965, at Catholic University in Washington, DC. Yaruss, Quesal, and Reeves (2007) presented a comprehensive review of self-help groups as an adjunct to stuttering therapy, addressing key goals and recommendations for participants including adults, teens, and children who stutter, in addition to parents and SLPs.

The self-help group described here enabled teens and young adults who stutter to discuss topics related to communication and life and engage in activities with others who had experiences that in ways were similar and in other ways were different. The clients decided the topics and activities and elected to receive modified direct treatment from the graduate student clinicians and the clinical supervisor (i.e., the author) as part of the group experience. Meetings occurred once per week for 1.5-hour duration.

The clinical process deliberately focused on collaboration (engaging in all aspects of the treatment process together, including planning, evaluating, and follow up), success (designing activities for – and later with, and eventually by – the clients so that each experiences improvement at every stage of the communication hierarchy as jointly designed, thereby yielding continued motivation and communication independence), and fun (genuinely enjoying the personal interaction and all treatment-related activities). Nothing is as motivating as success itself. Procedures included creating a “safe house,” tailoring to the strengths of each client, heightening the client’s awareness of his speech fluency, inviting objectives from the client, improving fluency facilitating techniques, addressing feelings and attitudes directly, facilitating transfer from the beginning, preparing for relapse, engaging the client and family as active members of an interdisciplinary team, and more (Shapiro, 2011). As a consequence of this process, mutual growth occurs and genuine bonds of collegiality and friendship are formed. It is not unusual to see candid emotional expressions, including laugher and occasionally tears.

The Graduate Student Clinicians’ Experience: Merging Classroom Instruction, Clinical Practice, Supervisory Conferences, and Applied Research

Five first-year graduate students completed a three-semester hour graduate seminar (Fluency Disorders, 16 weeks) during their first semester (fall 2015) at the Western Carolina University and then served on a treatment team during their second semester (spring 2016). The seminar and treatment team were coordinated by the author. The topics and projects in the seminar addressed but were not limited to:

• Theoretical and research foundations of fluency disorders, and how these inform current assessment and treatment methodology,
• Onset and development of stuttering from both developmental and longitudinal perspectives, and the nature and etiology of stuttering,
• Other fluency disorders with comparison and contrast to stuttering,
• Guiding intervention assumptions including intrafamily (i.e., personal constructs and family systems), extrafamily (i.e., interdisciplinary teaming and multicultural awareness), and psychotherapeutic (i.e., stuttering modification and fluency shaping) factors,
• Necessary components of an assessment and treatment plan for preschoolers and school-age children, adolescents, adults, and senior adults who stutter,
• Characteristics of the clinician and client-clinician relationship that are necessary for effective assessment and treatment,
• Components of professional preparation and lifelong learning for clinicians who specialize in fluency intervention, and
• New and emerging treatment strategies, evidence-based practice and evaluation of treatment outcomes, the value of self-help and mutual aid, clinical training and specialization, and global perspectives on the nature and treatment of stuttering.

The clinicians met in a supervisory conference once per week for at least one hour. Meetings initially were structured by the supervisor, but quickly were structured by the clinicians. Earliest meetings reviewed goals and expectations for and of the clinicians and the clients. Each clinician prepared an individual professional development plan to chart her own growth (i.e., delineating existing professional knowledge and skills and objectives for measureable professional growth) and an applied research proposal, which led to completion of individual pilot projects. The clinicians created a rotating system for handling clinical responsibilities (e.g., designing clinical activities and lesson plans, collecting data, completing required paperwork for accountability, collating and monitoring self-help activities initiated by the clients, and more). Emphasis was placed on clinical application and affective, behavioral, and cognitive growth of all involved – clients, clinicians, and the supervisor. Professional growth was documented on the bases of movement along the continuum of professional development, whereby each clinician progressed from receiving direct evaluation and feedback, to a transitional phase requiring less direct input from the supervisor, to eventual self-supervision. To accommodate the clinicians’ professional growth, supervisory styles transitioned from direct or active, to collaborative, to consultative (Anderson, 1988). Similarly, changes in the clinicians’ skills were observed, including:

• Perspective shifts (i.e., from their own perspective to the client’s),
• Dimensions conceptualized (i.e., from the client’s stuttering behavior only to the client’s thoughts and feelings as well),
• Activities and intervention methods generated (i.e., from their own ideas only to that of the clients, from the supervisor’s method only to their own with clear clinical and theoretical rationale), and
• Causal conceptualizations considered (i.e., becoming increasingly comfortable drawing from the existing literature and evidence basis to design and initiate original plans, branching out from the specific ideas and methods taught in the seminar). (Shapiro, 2011)

The clinicians and clients described their own perspective on the experience and the resulting progress, as follows:

Clinicians’ Views

Amanda:

“As a person who has never stuttered, I initially felt defeated when I began my first clinical rotation with PWS. It seemed impossible to understand their thoughts and feelings. If I couldn’t understand, how could I help? However, as I gained both knowledge in the classroom and experience in the clinic, I learned that competence as a clinician isn’t limited to personally having experienced a fluency disorder. The way therapy is provided is at least as important. Individuals who stutter need to feel valued, heard, and befriended, whether we have had similar experiences or not. The confidence I gained required a process that took time. Classroom knowledge, a beautiful supervisory example, and immersing clinically and applying information and evidence all guided my learning. I was privileged to experience for myself the freedom and joy that comes from knowledge and clinical application.” 

Lauren:

“Working with Dr. Shapiro and the fluency group, I gained so much knowledge. Professionally, I collaborated with other clinicians and PWS, shared diverse ideas, and decided on the best approach to ensure our clients’ success. I gained a better understanding of the nature of stuttering and how to design, implement, and monitor fluency treatment. Personally, I gained the ability to trust myself as a clinician and to trust my clients, as they are the most knowledgeable about their own communication experience. They can become their own best advocate; they can be the clinician’s best teacher.”

Christine:

“My experience with the treatment team was invaluable. There is no greater excitement than listening to your client use fluency controls on a difficult word and observing his confidence that results. I was one of five graduate clinicians on a collaborative treatment team that worked closely with the clients and professor. We met regularly, borrowed from the literature, and implemented each session with our own ideas. Our supervisory conferences were motivating and participation was natural because everyone’s voice was heard. I now feel confident to provide fluency therapy because my first experience was a successful team effort.  I recommend combining self-help with group therapy and collaborating with a treatment team to any clinician!”

Candice:

“Student clinicians are expected to apply classroom knowledge in the clinical setting. With Dr. Shapiro, we did this and more. We learned the importance of personal constructs for both clients and clinicians and how to design and implement treatment within this framework. Without the benefit of the seminar on fluency disorders and Dr. Shapiro’s textbook, I would not have been prepared for practicing as a student clinician. I would have been focused only on the behaviors of PWS, rather than addressing the affective and cognitive aspects of communication and the client-clinician relationship.”

Katrina:

“Participating in Dr. Shapiro’s fluency intervention group enabled me to learn the fundamentals of fluency therapy. From building relationships with the clients to designing intervention activities, the experience showed me how to approach fluency therapy holistically. While encouraging the clients to open up and reflect on their emotional progress, I pushed myself to reflect on my own insecurities and anxieties, resulting in personal growth and increased empathy towards PWS. Although I still have much to learn, this experience left me feeling confident in my ability to work with adults who stutter and collaborate with fellow clinicians.”

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Clients’ Views

Javan:

“My speech and I have had a complicated and challenging relationship. The transition from high school to college didn’t make things any better between us. Seeking help was the best decision I’ve ever made. My first year of speech therapy was eye opening. The most crucial thing I learned is the importance of awareness as a communicator. My ears are trained to hear both the fluency and disfluency while I talk. I believe this skill is vital because once you detect fluency, you can maintain it; once you detect disfluency, you can use reliable controls in the moment. After a year of therapy, I now have a thorough understanding of my speech and the confidence needed to be an independent communicator in this world.”

Joao:

“Two years ago, my speech was full of disfluencies, which negatively impacted my social life and lowered my self-esteem. It didn’t take long in the group to regain my fluency and self-esteem. I learned the importance of having confidence in myself and not being scared to say what I want. That is key to being an effective communicator. Now I speak to large groups of people with no problem. Social interaction has become easier. Talking on the phone and ordering fast food aren’t an issue anymore. The main reason for such success is the way the clients are approached. The clinicians and Dr. Shapiro are very well prepared. They always have great ideas and they invite our own so that we can help ourselves. Therapy creates a link of friendship and trust between the clients and clinicians.”

Taylor:

“Each morning when I awake, I have a set of fluency freedom tools at my fingertips that I can use to accomplish my daily communication tasks. No longer do I have to hide in silence! While my speech may not be flawless, I have what I need to control my speech. Dr. Shapiro has instilled in me that my speech does not have to be perfect, yet I should strive to be in control. I am now able to fulfill my lifelong dream of practicing as a healthcare professional, having just completed my Doctor of Physical Therapy degree, and helping patients daily with my controlled speech. This would never have been possible otherwise.” 

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Summary and Questions to Consider

There are as many methods for stuttering intervention and professional preparation as there are people who stutter and clinicians. The objective of both is clear: To enable each person to realize her or his own best potential. As we attempt to achieve this objective, we might consider questions that were raised by the student clinicians:

• What role does faith play within the clinical context? In what ways might the client’s faith in the clinician lead to communication success? (Amanda)
• How does the client’s experience of regular success within treatment contribute to a more positive treatment outcome? How might clinicians construct such successes? (Lauren)
• In what ways might PWS interpret humor differently than people who do not stutter? (Christine)
• How might the benefits of self-help, group treatment, and their combination be maximized for the success of each PWS? (Candice)
• In what ways do personal and social anxiety contribute to the communication experience? How can SLPs best support their clients when such anxiety exists? (Katrina)
• What methods of professional preparation best prepare clinicians to understand the uniqueness of stuttering and to work most effectively with PWS across the lifespan? (DAS)

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References

Anderson, J. L. (1988). The supervisory process in speech-language pathology and audiology. Boston: Little, Brown/College-Hill.

Bloodstein, O. & Bernstein Ratner, N. (2008). A handbook on stuttering (6^th ed.). Clifton Park, NY: Thomson/Delmar Learning.

Cooper, E. B., & Cooper, C. S. (1985). Clinicians attitudes toward stuttering: A decade of change (1973-1983). Journal of Fluency Disorders, 10, 19-33.

Cooper, E. B., & Cooper, C. S. (1996). Clinicians attitudes toward stuttering: Two decades of change. Journal of Fluency Disorders, 21, 119-135.

Corcoran, J. A. & Stewart, M. (1998). Stories of stuttering: A qualitative analysis of interview narratives. Journal of Fluency Disorders, 23, 247-264.

Emerick, L. L., & Hood, S. B. (1974). Preface. In L. L. Emerick & S. B. Hood (Eds.), The client-clinician relationship: Essays on interpersonal sensitivity in the therapeutic transaction (pp. vii-viii). Springfield, IL: Thomas.

Guitar, B. (2014). Stuttering: An integrated approach to its nature and treatment (4^th ed.). Baltimore: Lippincott/Williams & Wilkins.

Manning, W. H. (2010). Clinical decision making in fluency disorders (3^rd ed.). Clifton Park, NY: Delmar/Cengage Learning.

Murphy, A. T. (1974). The quiet hyena: Two monologues in search of a dialogue. In L. L. Emerick & S. B. Hood (Eds.), The client-clinician relationship: Essays on interpersonal sensitivity in the therapeutic transaction (pp. 29-44). Springfield, IL: Thomas.

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

St. Louis, K. O. (2001). Living with stuttering: Stories, basics, resources, and hope. Morgantown, WV: Populore.

Tellis, G. M., Bressler, L., & Emerick, K. (2008). An exploration of clinicians’ views about assessment and treatment of stuttering. Perspectives on Fluency and Fluency Disorders, 18, 16-23.

Yaruss, J. S., Quesal, R. W., & Reeves, L. (2007). Self-help and mutual aid groups as an adjunct to stuttering therapy. In E. G. Conture & R. F. Curlee (Eds.), Stuttering and related disorders of fluency (3^rd ed., pp. 256-276). New York: Thieme.