 About the Author: Rita Thurman has worked in the schools and in clinical settings in Utah, Idaho, Illinois, Montana and North Carolina since 1977. Her private practice in Raleigh, North Carolina and Bozeman, Montana focuses on the evaluation and treatment of children, teens and adults who stutter.She was awarded the Clinical Achievement Award by the NC Speech Language Hearing Association in 2012 and the Speech-Language Pathologist of the Year by the National Stuttering Association in 2015, both for her contributions to diagnosis and treatment for people who stutter.
She is a NSA Adult and TWST Chapter leader, and sponsors an annual Friend’s Workshop in NC. She is the Chair of the Executive Board of the American Board of Fluency and Fluency Disorders. |
Hope is a cognitive state, not an emotion (Zebrowski, 2013). The first time I heard those words was during a presentation by Patricia Zebrowski at the ASHA convention. It gave me pause because I had always thought of hope as an emotional reaction, something that was difficult to manipulate. The idea that it was a cognitive state, and therefore a skill we could wield to help children and adults who stutter, was empowering. This concept helped me develop a new perspective on my treatment protocols based around the clinical power of hope.
Time Travelers
The term “mental time travel” was first coined by the Canadian psychologist Endel Tulving to refer to our capacity for revisiting the past and imagining the future. Tulving claimed that these two abilities are related and rely on the same cognitive and neural mechanism. In other words, we learn from our past to make predictions and generate hope for the future. Studies on brain imaging (Maquire, Addis, 2000) have located that the area of the brain that controls for this skill: the hippocampus. When it is engaged, we are able to revisit the past and explore the future.
Unfortunately, I have met many children and especially teens/adults who stutter, who have negative memories of speech therapy and Speech-Language Pathologists (SLPs). Much anger, hurt, and disappointment often accompany their perceptions of speech therapy–especially if their past therapy was focused on fluency, wasn’t client driven or dynamic, and/or was led by a clinician unfamiliar with the person’s experience with stuttering (Markel, 2017). Now that effort has been placed on bridging the gap between people who stutter and SLPs, the cognitive and emotional aspects of treatment have moved to the forefront. Chani Markel’s wonderful paper in the 2017 ISAD demonstrates ways to facilitate that partnership.
By using “time travel”—what has been helpful/unhelpful in the past—in order to arrange for the future, there is an opportunity to use this way of thinking to build hope and improve treatment outcomes.
I have used “Time Travel” in my support groups to help teens and adults understand how to manipulate their optimism and hope. We set up time lines (What was going on with your parents when you were born? How was your first day in kindergarten? What was it like to ride a bike for the first time? Etc.) We talk about memories (good and bad,) and make predictions based on values/hope. During one teen meeting, a senior in high school related an experience he had in first grade when he was getting on the school bus and the driver asked him his name. He had a significant block and the bus driver mocked him. The levels of pain and hurt from that day transcend any amount of comforting 12 years later. My favorite comedian, Mike Birbiglia, has a formula: Tragedy + Time = Humor. But for people who stutter, the phrase “too soon” can sometimes last a lifetime.
Hope doesn’t mean that past and future events will always be great or that you will always look at the world as a wonderful place. Hope means that you can develop expectations for good events to occur. It requires a cognitive shift.
Separating Thought from Emotion
I believe that the thoughts we generate affect our ability to cope with situations. Excessive negative thoughts impact our ability to respond rationally. Thoughts occur naturally and are part of our cognitive system. How we manage those thoughts helps us turn direction away from despair and towards hope. The ability to use “Thought Defusion” (Harris, 2008) is a concept utilized in Acceptance Commitment Therapy (ACT). It is the process of manipulating your thoughts and thereby decreasing the negative impact they have on your behavior. In The Happiness Trap, Russ Harris explains ways to “distance your thoughts” in order to understand and manage them. Categorizing thoughts as being “helpful” or “not helpful” allows us to sort through and focus on the thoughts we want to hold dear or the thoughts we want to “sit on” for a while. It requires some flexibility, but it also requires persistence. Being able to shift and persist creates a level of optimism and therefore hope.
Rebel With a Cause
As Speech-Language Pathologists, our therapy for people who stutter has historically focused on the speech motor system. This is a system that is more concrete and easier to evaluate. A treatment program spawned from hope may be radical. Throughout society rebels can be viewed as difficult and disruptive. However, rebels can also be leaders, innovators, activists and teachers. In her book Rebel Talent: Why It Pays to Break the Rules in Work and in Life, Francesca Gino, a professor in the Harvard Business School, talks about how innovation is not always accomplished with expertise but rather curiosity.
As the Chair of the American Board of Fluency and Fluency Disorders, the organization charged with establishing Board Certified Specialists, I’ve seen the importance of this curiosity and rebellion. The best Specialists are lifelong learners. Independent of their level of training or years in the field, they look at each person who walks into your classroom/clinic as though they are meeting a person who stutters for the first time. They are meeting that person, and their experience with stuttering, for the first time.
Be rebellious. I challenge you to stop using words like: “Easy onset, continuous phonation (which is actually physiological impossible), pullouts (do you really want to use this term with teens?), cancellation, etc” These words imply: “To stop stuttering, all you need to do is….” This language minimizes the person’s experience with stuttering, it implies a simple solution to a complex problem. This mind set extinguishes hope.
Focusing on the development of hope and helping clients learn optimism is radical to the type of therapy in which most therapists engage. I will argue that it is crucial in working with children and adults who stutter.
Writing Therapy Goals that Focus on Hope
This is the section that every SLP is waiting for! All that rubbish is great to think about, what do I do in my session on Monday? How do I write an Individualized Education Program (IEP-used in the schools in the US) goal that is measurable? As SLPs we are accountable for measuring progress, so how do we write a measurable goal for hope? Perhaps we could use this simple mnemonic to do just that:
H: Heightened awareness of the stuttering moment.
O: Optimism that you can change behaviors and adapt to change.
P: Progress that the client understands and self-documents.
E: Efficiency in communication.
More specifically:
Heightened awareness:
John (not his real name) will identify and understand moments of stuttering in 8/10 instances across three speaking situations. He will understand the physical, emotional and cognitive components by documenting each.
The importance of identification for purposes of modification, desensitization, education and understanding is crucial. However, most important is how the client will manage this. Ask him/her to write a goal for this.
Optimism:
John will release the tension in a block and move forward to use the intended word in 8/10 trials across 5 speaking situations arranged in a hierarchy.
John will identify three unhelpful thoughts that are barriers to communication and describe ways to distance those thoughts in three speaking situations.
Optimism is bred from success, so set up treatment to make your client/student successful. Move from simple to complex and establish speaking hierarchies that are realistic and encompassing.
Additionally, have the client write two goals of their own that reflect taking on risks, ways to shift and persist, and/or ways to increase hopeful outcomes.
Progress:
Clients should be the ones documenting progress. They need to develop their goals and chart their own progress across those goals. These goals should not be only fluency driven, because that is fleeting, doesn’t always indicate that they had any impact on the outcome, and are too difficult to track across speaking situations. In short, fluency doesn’t matter.
This is where time travel becomes part of your therapy. Make sure your client is able to observe/learn from past events and learn optimism for future events.
Efficiency:
I hear the language “effective communicator” utilized excessively in our field. “Effective” is a value judgement. I prefer the term “efficient.” However, we need to be cautious. A person who stutters may find it most efficient and effective to word switch or manipulate the sentence to create fluency. Avoidance behaviors are like borrowing money from the bank, it only feels good for a little while. Have the discussion of efficiency in the absence of avoidance. Develop goals that that are truly individualized and client driven. Even young children can develop their own efficiency goals. One seven-year old child on my caseload wrote the goal: “I will raise my hand in class and give the answer, when I know it –9/10 times.” She followed this with, “If I stutter—it’s not like I am going to fall into a volcano and die…I will just stutter.”
In her book The Optimism Bias: A Tour of the Total Irrationally Positive Brain Tali Short states: “Hope, whether internally generated or coming from an outside source, enables people to embrace their goals and stay committed to moving toward them. This behavior will eventually take the goal more likely to become a reality.”
When our hopeful predictions turn out to be wrong, we simply learn from our errors and try again. We have a saying in my part of the world when things get tough: “Just put on your big girl panties and go to work…” Or “big boy” as the case may be and know that it is not a perfect world. In fact, Brene Brown once said: “Practice doesn’t make perfect, practice makes you realize you don’t need to be perfect” (Brown, 2010).
Be the source of hope for each child and adult who walks through your door for therapy. Guide them as they learn optimism. And as the old saying goes: “All’s well that ends well; if it is not yet well, then it is not quite the end.”
References
Bengtsson, S. Lau, H. and Passingham, R. (2009) “Motivation to Do Well Enhances Responses to Errors and Self-Monitoring.” Cerebral Cortex. 19(4):797-804 ·
Brown, B., & OverDrive Inc. (2010). The gifts of imperfection: Let go of who you think you’re supposed to be and embrace who you are. Center City, MN: Hazelden.
Gino, F. (2018) Rebel Talent: Why It Pays to Break the Rules at Work and Life. New York: Dey Street Books
Harris, R. (2008). The Happiness Trap: How to stop struggling and start living. Boston, MA: Trumpeter.
Markel, C. International Stuttering Awareness Day Conference (2017) “A World that Understands Stuttering: Bridging the Gap between SLPs and PWS
Maguire EA1, Gadian DG, Johnsrude IS, Good CD, Ashburner J, Frackowiak RS, Frith CD., (2000)“Navigational-Related Structural Change in the Hippocampi…” Brain growth and the cognitive map. Proc Natl Acad Sci U S A.
Sharot, T., (201) The Optimism Bias: A Tour of the Total Irrationally Positive Brain. New York. Random House.
Tulving, E.,N (2002) “Episodic Memory: From Mind to Brain,” Annual Review of Psychology. Vol. 53:1-25
Zebrowski, P., (2013) “The Role of Resilience in Stuttering Intervention for Children” American Speech and Hearing Association Annual Convention Presentation
Hi, Rita. This is a very nice paper. The HOPE goals are really amazing. I can think of many students who would love to work on these goals as a comprehensive approach to better communication. In my therapy approach I still believe in helping kids to increase the speech fluency through pausing and reducing the speech rate, although I’m leaning more and more toward HOPE. Traditional fluency enhancing strategies work for me, so I believe they could work for others who want to be more fluent. How could we reconcile the desire to become more fluent that many people have and the new trend of acceptance and HOPE?
It is good to hear that you have been able to manage your speech with fluency enhancing strategies (when you say it works for you.) I actually didn’t know that you are a person who stutters. We always need to keep in mind that every person who stutters has a different narrative.
You are right that some children can develop fluency speech in the therapy session using pausing and reduced rate of speech. However, as SLPs we need to create durable fluency and improved communication. Many children cannot access pausing and slower rate 24/7. The cognitive load is too great and impairs their interaction. Many children continue to struggle with blocks at a reduced rate, so all that is accomplished is slow stuttering. My HOPE is that we think about the whole child and allow them to say what they want, when they want regardless of their rate of speech.
Rita – I love the model and the acronym is so much more than a memory device.
The acronym aptly fits what we need to do.
In many ways, it frames what is already familir.
And at the same time, you continue to add and introduce novelty and nuance every time I listen/learn from you…
You know, it reminds of how one teenager shared the following with me, looking back on her “stuttering journey” and speech therapy experience:
“My therapist’s belief in me was more than I had in myself. I think that belief was a big part of my change.”
https://www.schneiderspeech.com/blog/stuttering-transformation
H.O.P.E.
Sometimes, it’s the best gift we can give someone.
And when they can’t take it or hold it for themselves… we can hold it for them.
Until they’re ready to take for themselves.
What a wonderful sentiment: “My therapist’s belief in me was more than I had in myself. I think that belief was a big part of my change.” It reminds me of the most important part of our therapy sessions. But, more I love: we will hold hope for them until they are ready to take it for themselves.
Thank you for your wonderful comments. I always learn from you!
Hi Rita!
I love this article, and feel it’s another example of how some SLPs are progressing in our ability to help people who stutter make durable changes in their real life.
Can you add to your comments on striving for efficiency? It’s an intriguing idea, but how do you relay this idea to your clients? I’m curious about all ages, but perhaps most curious about teens.
Thanks
Carl Herder
Good question! As linguists…we are linked to our language. Sometimes we need to let our clients choose the language that will ultimately lead to change. AND~Perhaps I was playing devil’s advocate to state I dislike the term “effective.” I feel it has been a little overused (which always makes a word loose meaning when it is tossed about without truly thinking about what it means) and want therapists/clients to use language that is genuine to them.
In Loryn, Stephanie and Amanda’s paper about disclosure they state: “communication effectiveness is diminished if gains in fluency are achieved through avoidance or use of speaking techniques that are burdensome and unnatural (Beilby et al., 2012).” This is what I am thinking about when I talk to kids/adults about efficient speech.
When I approach this idea of “efficient speech” I compare using various fluency shaping “tools”, word avoidance, filler words, tapping the word out, (listing the specific behaviors that they engage in or have been “taught”) with–staying in the moment, changing the tension, moving forward–while saying what you intended to say. Silence is uncomfortable and the moment may seem like a century, but the cognitive load for the later is significantly less. I chart in front of them what their reaction is in that moment using language that they have provided.
Then, after working on this “new way” of reacting in that moment, I say: “What would you call what you just did?” Whatever they say: “moving forward, sliding forward, changing the tension–while I said what I wanted to say”, etc–I write that down and it becomes our “efficient” or “effective speech.” The language doesn’t matter, it’s the concept of reducing the cognitive load, staying in the moment, fighting the thought demons that intrude on the moment and saying what you want to say. It is not easy.
Letting our clients direct therapy through their language–that they develop for each concept–will help them internalize the concepts more readily.
Hi Rita,
Your paper is simply superb, and I want to thank you, again and always, for being such an wonderful teacher and mentor to me.
I want to relate to a few points in the paper. Firstly, your statement that “fluency doesn’t matter” is spot on, of course. This statement should be the first statement in a first introductory course of study for SLPs. The focus on fluency has caused, and continues to cause, a lot of suffering of all those affected by stuttering: the person who stutters, the parents, and the clinician.
This leads to point of Therapy Goals. As you write, the person who stutters should be a key part in creating those goals. I believe that the role of the therapist here is to help guide the PWS away from fluency-focused goals, and towards Speaking goals. Out theme this year for ISAD is “Growth Through Speaking”, which in my experience completely fits with the non-fluency-focused goals that a therapy might include.
In terms of Efficient vs. Effective: Neither is really measurable, even though a certain company was founded based on the premise that speech efficiency can be measured, by the computer, and then stuttering can be solved one the “data” are available. Anyway, for me, the term Effective resonates more, since Efficient seems to imply a measure of time. “An efficient use of time”, for example. I feel that I am Effective in my speech when I (1) Speak instead of avoiding, (2) Say what I want to instead of saying what I feel that I can say without stuttering. Adding to this might be (3) Having my values guide what I say, but that might be stretching the point more than necessary here.
Whichever term one prefers, the example that you gave of a goal demonstrates what is important: ” “I will raise my hand in class and give the answer, when I know it –9/10 times.” She followed this with, “If I stutter—it’s not like I am going to fall into a volcano and die…I will just stutter.” “. Amazing! That is the way, in my opinion.
Thank you for mentioning ACT, and Russ Harris’ book. I feel that Diffusion is more about separating Action from Thoughts, rather that separating Emotion from Thoughts. For me, the thoughts (the storm of thoughts) create emotion. My choice point, to use Harris’ term, is deciding, in the midst of the emotional upheaval, how to act: in the direction of my values and the meaning to life that I have identified, or in the direction that feeds my misery. Further, if I sometimes choose a way that does not really help me, I should not be judgmental about it.
A thought about Hope, that might add to what you wrote: Mark Manson wrote a book about Hope, and he basically says, I think, that Hope implies that something still matters, that there is something that one cares about. I feel that your paper explains this so well. Hope is a cognitive state, as you write, and not simply optimism or wishful thinking. When we are able to decide what really matters, and what direction to take our lives in, that, perhaps, is part of Hope.
Thank you, Rita.
Thanks Hanan! You always keep me on my toes and thinking. As I read your comments, I remember why it is so fun to do workshops with you. You challenge my thinking and language–making me a better therapist/person, HOPEfully!
Writing goals with clients is crucial for dynamic-client driven therapy; however, it often challenging. Clients come to me because they want to stop stuttering. Do I rob them of hope when I discuss the chronic nature of stuttering? A little? There is a lot of work involved in guiding a client– who has been told that they can stop stuttering if only they gave it an honest effort. I didn’t even touch on the cognitive restructuring that this involves… maybe a paper for next time. You should write it! My goal is to convince therapists that the client must be the one setting goals.
You make a great point about defusion. Separating the thoughts from the emotion is essential–but, first you need to recognize which of those thoughts can be helpful or unhelpful. Sometimes that step in itself provides some distance before it creates an emotion. But the thoughts and emotions do intermix and confuse. I have a little mantra that I say: Is this my emotional brain working or my cognitive brain? Sometimes thoughts and emotions come at you so fast that you just need to react quickly and move to: what are my values in this situation? And yes, no judgement if it turns out that my decision may not have been the best in the heat of the moment.
You are right about the language of efficient and effective. Neither can be measured by a behavioral scientist, but they can be by the person in that moment. I think of “efficient” in terms of cognitive load. Was I thinking about the message I wanted to say, or how to use a multitude of fluency enhancing skills to make that message fluent? Perhaps the best route is to describe the value and ask the client to create the language.
I need to add Mark Manson to my reading list. I love the idea that hope implies that something still matters. Thank you for your amazing comments!
This is a fantastic paper! I really liked the “HOPE” mnemonic device and the goals you mentioned were spot-on. “The Happiness Trap” is one of my favorite books to reference when talking with teen or adult clients about attitudes and emotions regarding stuttering. The illustrated version (looks like a graphic novel with abbreviated content of the original version) can be helpful to use with bright upper elementary students as well. Thanks for such a great resource and I appreciate the shoutout 🙂
Thank you Chani! The shout out was well deserved! Thank you for the information about the illustrated version. I have used his Youtube animated activities and will add this one to my list.
Rita,
This is SO good. Thanks so much for sharing it!
Joe
Thanks Joe!
Hey Rita,
Congratulations on another thought provoking paper! Re: speech tools and techniques, such as “continuous phonation” and “pullouts,” I am reminded of a story I heard about the legendary Hugo Gregory. Re: clients pushing back against techniques and complaining that “it” didn’t work, or “that” didn’t work, he reportedly would always say, “Its not a ‘that,’ it’s not an ‘it,’ it’s YOU!” It’s you, and being present in your own body, and noticing the way something feels, and making those connections. … I love this! Thanks for sharing your terrific paper.
Rob Dellinger
Thanks Rob,
You (and Hugo) make a great point. Allowing the person to know that they are the one in that moment, experiencing that reaction and fighting to manage rather than some nebulous tool they reach for in the air. This can increase their understanding of stuttering and their reaction to it. I appreciate your kind words and keep up all the great work you do with our kids in the schools.
Good Morning Rita-
I wanted to thank you for addressing how to measure change/progress in the schools. To me, the social-emotional-psychological change is the most important in people who stutter, however, schools require an objective measurement. This is a very difficult thing to quantify, however, your acronym and examples are amazing. This is truly a resource which I will refer back to. The way the goals are written still provide measurement but allow the subjective component necessary for appropriate therapy with people who stutter. Unfortunately, and sadly, many people measure progress by how “fluent” a person who stutters can become with therapy. H.O.P.E changes the ideology. I think this paper is very insightful and informative to anyone, not just SLPs. Additionally, your paper advocates that we can be better, and we should be better.
Thank you for this insightful paper,
Mackenzie McBride
Thanks Mackenzie! You are so right! People measure success in stuttering therapy by how fluent a person is in that moment. The problem is that situations matter and fluency can be a fair weather friend. If a child/adult is having a fluent day–it may not be anything that they are doing to manage their speech. They just got lucky. Additionally, whenever I have a client tell me that they are having a week with more stuttering, I always say: “Well, you know it is not anything you (or your parents/teachers/friends) did wrong! Stuttering just happens.” So, measuring fluency is” not really a valid measure of progress. The day that we can eliminate this goal in IEPs and private clinics–The child will be 90% fluent” –will be the day we have finally made the necessary change in therapy that is so needed.
I have teachers tell me all the time: “She is doing great in class. I haven’t heard her stutter once.” I always ask: “Did she talk in class?” Yes, we can make all children and adults fluent if they don’t talk, reduce their sentence structure, use “tools” that are so cognitively laden that the message and interaction is impaired. I will argue that we don’t want that kind of fluency.
We have a lot to do to educate teachers, parents, clients and other SLPs. Thanks for your help in doing just that!!
Thank you for getting back to me Rita, I appreciate your insightful feedback!
Mackenzie
Rita,
I appreciated how you clearly outlined the components of H.O.P.E. and gave specific examples of goals and how to implement it. This is very helpful! I loved that you shared your experiences and learned from them. For example, age 7 is younger then I would’ve expected to be able to define what efficient speech means and create a goal for it. How do you address the “mental time travel” aspect with young children? Teaching them to reflect and notice progress is important, but is something that kids seem to have an easier time with as they get older. If I’m lucky, the younger students will have one thing that comes to mind from the previous week, but often not even that. Any tips on how to teach this skill?
Thank you,
Jessica
Good question Jessica! Many young children are living in the moment and have difficulty with temporal concepts because they are not there developmentally. I also have a hard time getting kids to remember from week to week what we talked about/worked on the previous session. However, I have found if there is a highly emotional component to the discussion, it sticks with them. I will work on regulating behavior while talking about their birthday–they always remember that and can easily relive the excitement of the day. With younger kids I also try to keep activities very visual. I have an enormous glitter jar that I put an animal in each week. When little ones are having a hard time regulating, I stir up the glitter and have them use some calming activities to “settle their glitter” and watch until the glitter is “clear” and they can “see clearly.” I have found that the kids can tell you every animal that they have seen in previous weeks in the glitter jar. Sometimes, just saying–“I need to calm my glitter–you need to calm my glitter” is enough to call to mind those self regulatory skills. I must warn you spouses never appreciate it if you say: “You need to calm your glitter!”
The other thing I find crucial is letting children choose the language they use in therapy. When I demonstrate a concept, I say–“hmm when you do that, what would you call it?” I write the language down and use it from week to week.
Thanks for your questions! The children you work with are lucky to have you!
Thank you for the ideas! I found the glitter jars online – so fun and easy. ? I can see how the kids would respond well to the visual.
Rita,
I found your contribution to be insightful, humorous, and peppered with excellent advice. I, too, have thought as HOPE as an emotion, not a cognitive state. I started my “ACT: Acceptance Commitment Therapy” journey this year and find it pairs well with your discussion of HOPE as a way to develop expectations for good events to occur.
I am a graduate student that is currently treating fluency clients and welcome any advice you have in creating a client driven session that moves beyond the focus of fluency and into the social/emotional/psychological change. The examples of the “HOPE” driven goals are very helpful.
Thank you for this very thought provoking work.
Erma Hanson
Thanks Erma! I appreciate your kind words! Yes~Hope driven therapy aligns nicely with ACT. I have seen several cognitive behavior therapies emerge over the past 40 years, and ACT seems genuine to me and an approach that applies to many life challenges.
thanks for reading!
Rita,
Your writing ties in many of the things I’m learning about as an SLP graduate student. I’m working to integrate mindfulness, Acceptance Commitment Therapy (ACT) and aspects of counseling into a treatment plan for an adult client. This aspect of hope, that it is a cognitive state (a learned skill) may be the missing piece for me. I have been trying to work out how to help my client believe that acceptance is going to be worth it. Thank you for presenting this information in such a clear fashion and for providing the examples. I’m excited to work this into my “tool box”.
Regards,
Tabitha Syme
Hi Tabitha,
I would advocate that the reason your client won’t realize the “acceptance is worth it” is because it is your value, not his/hers. Once it becomes the client’s value, it will happen organically. I am not a fan of the word “acceptance” even though it is the language used in the cognitive behavior concepts I advocate. Acceptance to many people means “giving up” or “throwing in the towel.” Acceptance is so much more than that and I use “recognize” instead…the language just seems less loaded. “I recognize that I stutter, I notice that I have these negative thoughts.” I also think that the person needs to have compassion for themselves before they can make a step towards acceptance. Being able to forgive yourself when you felt that you didn’t “measure up” is a way to initiate the journey of acceptance.
Thanks for adding to the discussion. I am learning so much!
I really appreciate your response. Such great insight! Thank you again.
Good Afternoon Rita,
Thank you for your thought-provoking approach to treating stuttering through H.O.P.E. I appreciated your (and Zebrowski’s) perspective on hope as a cognitive state, and not an emotion. It gives us more control over obtaining and maintaining a hopeful mindset in treatment.
You mentioned that many teens and adults who stutter, have negative memories of speech therapy or moments of stuttering from their past. You also stated that our thoughts affect our ability to cope with situations. Do you have any advise or suggestions for helping our clients who stutter to distance their painful/negative memories in order to manage them, and treat the memories as more of an object or event to learn from than a past emotion? Your article did mention “Time Travel” and creating a timeline of events and future predictions. How important or essential is it for the child who stutters to have this timeline in a group setting? Is it just as effective in an individual setting? Does it take multiple exposures to the concept? You provided the formula: Tragedy + Time = Humor. Is there anything that we as speech-language pathologists can do to help our clients with the “time” component or distancing themselves from that experience to invite the humor?
Thanks,
Cami Finehout
Welcome to an amazing profession! How exciting to be a graduate student during a time when we have such advanced knowledge about stuttering and what helps people who stutter. Having knowledge of ACT in the treatment of stuttering is pivotal! We need it to help our clients and we need it to help ourselves. However, not all clients are willing to direct their therapy or even discuss openly their concerns. They come to us because they want to stop stuttering. How do we shift that to acceptance and management? They often come to me with baggage from other therapists who have given directives like: “all you need to do to stop stuttering is….”
Developing a therapeutic alliance is the first step. There needs to be a climate of trust and shared values. One of my teens last week told me: “You know that I am only doing this because I trust you.” Those words melted my heart.
Next there needs to be a lot of discussion about goals. I usually throw out a goal like: “John will identify stuttered syllables in 3 speaking situations.” and then say: “Wait, what do you think that means?” Whatever he says, I rewrite the goal to use his words.
Discussions about “what is important” need to occur on an ongoing basis. In the beginning stages of therapy, I usually hear the child/teen/adult say that the important thing is to be fluent with a teacher/boss or in a presentation. Discussions of fluency can lead to unveiling avoidance behaviors and their detrimental results.
Sometimes I tell my kids: “I forgot to plan your lesson today. What do you think we should do to help your speech today?” At the end of each session, I say: “I had so much fun today I forgot to write your notes. Tell me what we did so I can put that in the file for you mom/teacher.” This lets me know whether or not the child has internalized the concepts.
I hope this helps and keep the questions coming. The most success comes from curiosity, not experience!
Hi Rita,
Your paper is beneficial and informative. I am a graduate student in speech-language pathology, and I find your approach to writing treatment goals so unique, clear, and very client-specific. I loved how you redefined what a rebel can be, mainly when writing goals for clients who stutter. I hadn’t realized that even using the fluency strategies such as easy onset and pullout already carried the connotation that the client’s speech needs to be “fixed.” The way you write goals with the HOPE mnemonic already sound more positive and I can see how they can motivate the client even more because they are goals related to what they’re experiencing (such as the goal that targets a reduction in tension during a block), especially if they contribute to the goal-creating process. I have asked clients what they would want to work on in treatment related to their stutter and weren’t able to respond to the question with much detail. However, applying the HOPE format and discussing it with the client, I can see how this may help them understand the process more and be able to collaborate more with them.
Thanks,
Viviana
Hi Viviana,
It is so exciting to see all the dynamic graduate students participating in the conference! You make a great point about clients not always being able to direct therapy or write their own goals. I have stolen ideas from Vivian Sisskin about ways to accomplish this. Discussing values and creating a “value scale” can help you navigate client driven goals. An example of a “value scale” is putting “saying everything on want” on one end of the line and “speaking perfectly fluently” on the other end of the line. Ask you client; “What is most important to you and where you you place your mark on the scale.” Wherever they puts their mark, it opens up discussion.
If you allow a space for the client to feel comfortable, frame your questions as comments (I wonder….) and give him/her time to talk, their values will become evident and allow you to create goals based on them.
Warm regards,
Rita
Thank you Rita!
I am in a class on assessment and treatment for people who stutter. I really enjoyed your insight. I think that your framework for goal development makes a lot of sense. I especially feel a connection to your statement that “avoidance behaviors are like borrowing money from the bank, it only feels good for a little while.” I wonder how much we would understand from the covert aspects of stuttering if only we could see them. As a child in grade school, speaking in class was one of my largest fears, and I am a fluent speaker. I try to empathize with avoidance behaviors like these because I can imagine the fear of judgment.
There’s one point that I’m wondering if you could clarify. What are the benefits to having the client track documentation, and is there an evidence base for the outcomes? I’m unsure of how most kids would do with this task, thought it sounds good in theory.
Thank you,
Amanda
What a thought provoking idea–if only we could see those covert behaviors. I am going to use this in therapy. I will tell my clients; “suppose I could see all your covert behaviors for a day?” ~sort of like that movie ‘Liar, Liar’ where a magic spell makes an attorney tell the truth for a day. What a great concept!
As for clients documenting their progress–I don’t know of any research conducted on this, but what a great idea for one of the graduate students on this forum. When I think about it–who is the most important person to see progress if your treatment is hope driven? The client is the one who should be aware of it and they becomes intimate with the therapy process when they are the ones documenting progress. It also makes them actively engage in directing therapy, teaches them to advocate, and empowers them. This is what I have seen anecdotally and it makes sense to me. When you are the only one keeping data, how does the client understand their accomplishments and areas for improvement?
Hello Rita!
I am a current SLP graduate student and I am commenting on behalf of myself and two group mates who have read your article. We would first like to thank you for sharing your wisdom in working with people who stutter! We are currently taking a course on stuttering and we have been able to connect what we are learning in class to the experiences you talked about. Your HOPE framework is very helpful in understanding goal writing for our future clients. In your article, you mention the importance of client driven goals and having the client take an active role in their goal formation. How do you go about having your clients be active participants in their own goal writing?
Thank you,
Alison, Julia, and Madeline
Hi Rita,
I love Mike Birbiglia too! I will check out the books by Francesca Gino and Tali Short as I haven’t read those yet.
Thank you for providing practical examples of holistic treatment goals. It can be easy to make choices for our clients, but serving as a guide for our clients’ growth is a greater challenge. While sitting at home tonight writing an IEP for a child who stutters, I will insure that I include HOPE as the primary focus of treatment.
Thank you!
Taylor
Thanks Taylor,
Mike is the best! I apologize for the delay in my response. I read this the first time and smiled. Today I decided it really needed a response. Please know the amazing impact that you have on these children by bringing them a compassionate, thoughtful therapist. You are their hope.
Hello,
As an undergraduate student in Speech Language Pathology, I find your HOPE acronym to be very helpful for people with stuttering disorders and it is something I will keep in mind as I further progress my education in the field. Although I really liked what you said about being rebellious and how it is a good thing to be a rebel, do you have any advice on how to be rebellious either in the field, how to teach our clients to be rebellious, or in life in general?
Thank You!
Erin
Hi Erin,
I thought that I had responded to your comment and going back through this morning, I realized it slipped by.
If you think of rebellion as advocating for yourself, developing resilience and getting outside your comfort zone–you have the key components to teach your client rebellion. Playing games like Ultimate Werewolf is great for teaching teens how to advocate for themselves. Developing speech hierarchies that discuss different situations and how difficult it can be to push oneself in that situation helps them recognize that stuttering is not their fault. It just happens and situations matter.
If you equate rebellion with curiosity…you will develop their skills that way. Keep them asking questions and talk through difficulties together. Have fun together. Look at that individual sitting across your therapy table as a child, not a disorder.
Hello Rita,
Thank you so much for your analogies and insights. There is so much practical application in your words. I am an SLP graduate student, and I absolutely love that the field is recognizing thought management as integral to the treatment journey. You give me hope for each of my future clients with your framing of hope as a cognitive state! I have a supervised clinical placement with a 9 year old in a public school, and I am interested to hear thoughts and suggestions regarding how to handle IEP goals when it is the parent who demands “fluent” speech. Are there ways to facilitate a conversation to help parents see the value of “efficient” communication when they themselves don’t seem to have an understanding of the larger impact of the stuttering experience on their child?
Hi Chanah,
Parents are an important part of the therapy process. Many times I have heard SLPs say; “it doesn’t bother the child (which I don’t always believe is true and if they did a cognitive-affective test they would find out otherwise) and the parent is the only one concerned.” Of course the parent is concerned. They visualize a life time of struggle. They have seen how stuttering is treated in the media. They don’t want that for their child. They are right to pursue therapy. If we saw a 9 year old who wasn’t reading, would we say: “Oh, they aren’t really interested, so let’s not pursue it?” Communication is a basic human need and parents recognize it.
So, first–respect the parents concerns. Then, guide them to the values they want for their child and help then realize that stuttering is chronic, but not without hope for management. I would say that parents do see the larger impact of the stuttering experience and may be going through the stages of acceptance and need direction. This can be done through discussion, but also through meeting other parents of children who stutter. Get them to NSA or Friends. You could even have a “parent meeting” within your facility. Parents need support too and talking to someone in that same situation will accomplish that.
thanks for your questions!
Rita
Hello Rita,
Thank you so much for addressing this topic. I really appreciated the way that you discussed looking at hope as a cognitive state, not just an emotional reaction. This representation really allows people to look at themselves as in more control, than when they look at hope as an emotional reaction. I also loved the outline of HOPE for writing clinical/IEP goals. As an educator we discuss the concept of “grit”, which seems to align well with your representation of HOPE. I was wondering if you have ever discussed “grit” with students or tied it into your clinical practice?
YES! Grit and resilience is key in the discussion of hope. I talk about resilience and determination in all my therapy groups and individual sessions. I think that children/adults who stutter need to understand that resilience plays an enormous role in living with stuttering. Thanks for making that point!
Hello Rita,
Thank you for sharing your paper, as it was very educational and enlightened my clinical perspective. I am a second year graduate student in speech-language pathology and am currently taking a fluency disorders course. We have not learned about creating goals yet, therefore I found your HOPE mnemonic to be insightful and clear. I enjoyed how these goals can show and track progress. One part I found surprising was how clients should be the ones to document the progress. What is your reasoning behind this?
Thank you,
Rebecca
Hi Rebecca,
Great minds….you are not the only one who asked about the rationale behind getting clients to document their own progress. See my response to Amanda’s above and thanks for you all asking these provocative questions!
Rita
Hello Rita!
Thank you for your approach! I appreciated the perspective you emphasized on hope as a cognitive state, which I had not put much thought into prior to reading your paper. I think writing IEP goals around thoughts of hope and optimism is very insightful, and I am thankful for your examples of goals as a graduate student with minimal experience in that area.
As you discuss “time travel” in support groups, I am curious, what would be the youngest age you might utilize this with? I imagine younger children not quite understanding the concept of time but would benefit from this as early on as possible.
I love that your paper provides thought-provoking and new ideas into working with clients who stutter, but also the practical application to all areas of life. This is a reference I plan to save and throw into my clinical toolbox.
Thank you again,
Alison
Hi Alison,
You ask a great question about the age with which you can do the time travel activities. Many young children are living in the moment and have difficulty with temporal concepts developmentally. I have a hard time getting kids to remember from week to week what we talked about/worked on the previous session. However, I have found if there is a highly emotional component to the discussion, it sticks with them. I will work on regulating behavior or talking about the past while discussing their birthday–they always remember that and can easily relive the excitement of the day. With younger kids I also try to keep activities very visual. I have an enormous glitter jar that I put an animal in each week. When little ones are having a hard time regulating, I stir up the glitter and have them use some calming activities to “settle their glitter” and watch until the glitter is “clear” and they can “see clearly.” I have found that the kids can tell you every animal that they have seen in previous weeks in the glitter jar. Sometimes, just saying–“I need to calm my glitter–you need to calm my glitter” is enough to call to mind those self regulatory skills.
Engaging children in time travel concepts, teaching them to learn from the past and gain hope for the future needs to be developmental and pertain to each individual as some children grasp temporal concepts more readily than others. Take one child at a time to apply these concepts.
hope this makes sense!
Rita
Hi Rita,
That does make sense and I appreciate you taking the time to provide that advice! I like the idea of the glitter jar and can think of a number of children who would benefit from that strategy.
Thank you again!
Alison
Hello Rita,
I am a 2nd year grad student who is working with my first fluency clients this semester. I really enjoyed reading this article, and the message that it sends: that hope and optimism are more important than just speaking fluently. The more I learn about people’s experiences with stuttering, the more it makes sense that targeting the emotional piece is likely so much more crucial to the PWS’s happiness than just ‘speaking fluently.’ And I really like the idea of mental time travel where a person can reflect on their experiences and use them to create a more positive future… it’s especially neat how you use this strategy to have your clients create a their own goals. What better way to make therapy relevant to a person’s life than to have them direct you towards what they want to accomplish.
Thanks for the thought-provoking article!
-Zoey
Thanks for your kind words Zoey! You have a fun, exciting career ahead of you and I love the spunk that you are bringing to the field!
Enjoy!
Dear Rita,
Hi! I am a 2nd year graduate student and I enjoyed reading your paper. The moment I started reading your paper I was extremely intrigued and interested in the direction your thought processing was heading towards with the concept of HOPE. As a graduate student, I have not had many fluency clients yet, but I like your HOPE approach. I have been told to use SMART goals to prepare for my therapy sessions. These goals are not always measurable for each individual, such as a client who stutters. HOPE goals are truly tailored to the person and each goal is measurable to their own needs. This paper has provided me with a better understanding of stuttering and how hope can not only improve an individual’s therapy session but help gain a positive outlook on life.
My question for you is how you came up with each goal for HOPE? Did you take into consideration previous experiences and/or ideas from other individuals who have experienced difficulty with stuttering on a daily basis? When I enter the field and become a Speech-Language Pathologist, I want to be able to tailor the therapy sessions according to the needs of the client, but also providing them with hope and showing them positive outlooks can improve the day to day life.
Dear Rita,
Hi! I am a 2nd year graduate student and I enjoyed reading your paper. The moment I started reading your paper I was extremely intrigued and interested in the direction your thought processing was heading towards with the concept of HOPE. As a graduate student, I have not had many fluency clients yet, but I like your HOPE approach. I have been told to use SMART goals to prepare for my therapy sessions. These goals are not always measurable for each individual, such as a client who stutters. HOPE goals are truly tailored to the person and each goal is measurable to their own needs. This paper has provided me with a better understanding of stuttering and how hope can not only improve an individual’s therapy session but help gain a positive outlook on life.
My question for you is how you came up with each goal for HOPE? Did you take into consideration previous experiences and/or ideas from other individuals who have experienced difficulty with stuttering on a daily basis? When I enter the field and become a Speech-Language Pathologist, I want to be able to tailor the therapy sessions according to the needs of the client, but also providing them with hope and showing them positive outlooks can improve the day to day life.
Thanks for reading and I appreciate your question.
Many of the goals I list are drawn from Bruce Wampold’s work on therapeutic alliance and from working with children and adults who stutter for over 40 years. It also takes into account the number of clients I have seen who received inappropriate therapy that created shame, added to the cognitive load of the client and set up unrealistic expectations. This is the one type of speech therapy that SLPs engage in(and maybe swallowing therapy) where bad therapy is more detrimental that no therapy.
Every client you see needs to have individualized therapy that is dynamic and client driven. I don’t think you need to give them “positive outlooks.” I would argue that using terms like “positive” and “negative” are too judgemental and not necessary for the concept of hope. Encouraging a person to “think positive” about their stuttering often minimizes their experience. No one wants to stutter and sometimes it is hard to feel positive about something so invasive. Hope is the idea that something matters…not that everything will be positive.
I love the meaning you gave the word hope. I also really enjoyed the line you wrote about professionals acting as they have never seen a person with a stutter because no two people ate the same. How long would you recommend therapy using the Hope protocol?
You ask a great question. As SLPs we are trained to think about “discharge” or completion of goals. With the chronic, episodic nature of stuttering, we need to think about treatment differently that the other children and adults we see at our therapy table. Support for people who stutter needs to last a life time. Goals may shift and we won’t work on “H” and heightened awareness, but development of “O”; optimism through connecting our clients with support networks, should be ongoing. For a school age client, that direct therapy may shift to consult. For a teen or adult, that direct therapy may shift to connecting with them during support groups. When I see a child who stutters on my caseload, I hope to be a part of their life as they grow, face new challenges and move into adulthood. I have been lucky to watch that growth in my community, given that I have been in private practice here for over 30 years. I have a children’s support group, an NSA TWST (Teens Who STutter) and an adult support group. I watch people move through each group as they grow and the power of support groups should not be underestimated.
So, I guess what I am saying—How long would I recommend therapy using HOPE? I never give up on hope=)