 About the Authors:
Daniel Shaw, MS, CCC-SLP, is a speech-language pathologist at the Vanderbilt Bill Wilkerson Center in Nashville, TN, where he serves children, teens, and adults who stutter (along with their families). He also serves preschool-aged children with autism in the Preschool For Children With Autism and coordinates parent education for the program. He loves to read, write, teach, and expose his family to the great outdoors. He is also a fan of hide-and-seek and has been known to instigate Nerf wars around the house.
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When we consider “One Size Does NOT Fit All” as speech-language pathologists (SLPs), what is our role in stuttering treatment?
Conventional wisdom in the sub-field of stuttering evaluation and treatment calls on clinicians to meet their clients (and families) where they are. Change cannot be forced on anyone, and as clinical psychologists William Miller and Stephen Rollnick have argued, those who are not yet ready to change will simply supply their own arguments against change (Miller & Rollnick, 2013). This will inevitably lead to behaviors which support those arguments. In other words, change must begin internally, manifest its readiness in language, and then lead to sustained action. This view comports with the available research and encourages speech therapists (in our case) to start with the client rather than a preconceived and rigid plan of action. One size simply does not fit all.
Yet, there seems to be some confusion over the well-known principle: meet clients where they are. Many in the field use this language synonymously with a call to “do as clients wish,” whatever the request and whatever the consequence, thus decontextualizing its potential benefits. It is this latter implicit direction which fails to take into account the very nature of stuttering and its impact. An open-ended conversation with a person who stutters can yield the problems associated with stuttering: shame, guilt, embarrassment, fear, anxiety, saying less, staying home, hiding, hopelessness, concealment, unwanted thoughts, diminished self-worth and confidence, dread of conversation, and physical exhaustion. While this list is far from exhaustive, it is intended to paint a picture of a life which is ruled (in many cases) by stuttering or even the possibility of stuttering–a life in which decisions are made to minimize social stigma and other potential consequences of being a person who stutters. The bad news is that these are not hypothetical consequences for stuttering in our day and age. The good news is that none of these consequences are endemic to stuttering and thus, can be discarded and changed if desired.
Speech therapists possess a unique mixture of specialties in motor speech, counseling, pragmatics, and behavior change, and are in an excellent position to support people who stutter. We can do this by asking open-ended questions to elicit their personal experiences, challenges, resources, and hopes, all from the perspective of a person who stutters. However, we do not merely want to understand their problems or the nature of their problems. We also want to understand the types of change (if any) they desire to make. Broadly, this may sound daunting, or conversely, intuitive until beginning the conversation, only to find that this is easier said than done.
Given the nature of the problem, it is important to know how the client views his or her communication and what he or she is prepared to do about it. The response by most newer clients (or families) is that stuttering is the problem and fluency is the solution. In most cases, clients have not considered the problem beyond these bookends: stuttering and fluency. Many clients appear to lack an imagination beyond an undefined future hope: fluency. When asked what this would mean for them, many struggle to expound on their initial responses. “What would your family notice (or notice you doing) if you didn’t stutter anymore?” Many respond, “Well, they would notice that I’m not stuttering.” This response and many like it evidence a belief that there are only two choices: to stutter and live as “broken” or find fluency and finally begin to live. These choices will be expressed in myriad ways but evidence the same core belief that speech fluency is the only way out of their problem(s). If clinicians simply “give the client what he/she wants,” it will feed these false beliefs and reinforce the notion that fluency will give them what acceptance cannot. If we, instead, pivot to probing their experience of stuttering and the future they envision (if stuttering were no longer an impediment to living the life they want), both client and therapist will begin to peel back the facade of the “fluency solution” and discover the gems hidden below the surface. We simply have to be willing to mine with them.
We intend to argue in this paper that it is the job of the therapist to elicit insights into the nature of stuttering and explore associated problems with clients and to illuminate the variety of choices for communication with guidance in achieving whatever desired outcome is expressed. The key is “informed desired outcome,” but what do we mean by this? As aforementioned, sometimes the individuals we serve, young and old, come to speech therapy with a valid desire, even need, for fluency that is often informed by a limited view and understanding of stuttering. This is heavily influenced by recurring negative listener reactions, trauma experienced due to stuttering, cultural views surrounding differences, societal norms of what is acceptable or preferred, as well as internal and external pressures for fluent speech. Let’s imagine for a moment the first time one experiences the ocean. What’s the difference between swimming in a lake versus swimming in the ocean? You might be content with lake water if you know nothing different, but once you’ve seen and experienced the clarity and beauty of the ocean, it’s unlikely you’ll desire lake water again. What if our role as SLPs was to guide our clients/students to see the beauty of the ocean of spontaneous and joyful communication rather than remain in the murky waters of fluency at all costs? A shift of this sort would see SLPs as guides in expanding a client’s imagination of what is possible, slowly removing the blinders to enable them to see the panorama. Seeing a possible preferred future which was previously unimaginable can lead to hope, the belief that what is possible might be probable. And increased hope can lead to genuine choice. After all, who chooses an option which they believe is not truly possible?
It is here that an important qualifier must be added and that qualifier is this: each client brings unique personal experiences, readiness, personalities, values, and personal resources which will impact and inform the change(s) they make. It should be noted that this is an aspect of meeting clients where they are which should be upheld. Clients must have complete autonomy over their treatment and the pace of the work, even while clinicians play a role in shaping that experience and coaching or guiding clients toward their preferred future.
Joze Piranian, speaker, comedian and person who stutters, presented a similar idea with a different lens when giving a keynote address at the 2023 NSA conference. He shared a quote by Persian poet Rumi, which speaks to the work we do with people who stutter, “Why do you stay in prison when the door is so wide open?” As SLPs, it’s a beautiful picture of the power of treatment when we help people finally see wide open doors in order to come out of whatever “bondage” they find themselves in (i.e., limitations, restrictions, confinement due to stuttering).
In a recent video depicting positive outcomes of effective speech intervention (https://youtu.be/l4pddgtEH3g)
We will presume you are fully convinced by this line of argumentation and speak to the “how” of expanding realms of possibility in everyday life. Motivational interviewing and solution-focused brief therapy provide helpful models of questioning which ask the client to “use your imagination” to discuss what might be different if the problem were suddenly gone. The focus is on positive solutions to the problem at hand, what the person would be doing that he or she is not doing now, or is doing now but might hope to do even more. The therapist reflects these responses back and provides additional questions to “mine” for concrete behaviors (gems) which might become actionable. For example, responses such as “I would be happy” or “I wouldn’t feel so afraid” are insightful but offer no clear opportunities for concrete change. The clinician might then ask, “If you were happy, what would be different?” or “If you felt happy, what would that free you up to do?” Solution-focused therapy often utilizes the question, “And what difference would that make?” or “Suppose that happened, what would be different?” to delve further into this hopeful future. These conversations often generate lists which can be shaped into goals and insights into the changes a client would like to make. I want to talk more, I want to give better eye contact in presentations, I want to have fuller conversations (rather than cut them short or say as little as possible), I want to ask questions in class. These responses reach far beyond “fluency” and into the everyday life of a client. In the same way a client may state, “I want my stuttering to go away” or “I want to be more fluent,” a client may also state, “I want to introduce myself to new kids at school.” Unless SLPs ask the question, many people who stutter might never share these hopes. Indeed, a client might never voice these hopes because he or she does not consider them worth uttering. The key is taking small, tangible steps over time which lead to meaningful changes. Books and articles by William Miller, Stephen Rollnick, Kidge Burns, Insoo Kim Berg, and Steve de Shazer, can help to flesh out the methods discussed briefly in this paper in greater detail.
In summary, “One Size Does NOT Fit All” means that it’s not only ethical and reasonable for SLPs to serve as guides to worlds unexplored, but it is our role and responsibility to do so. We carefully cultivate a culture in which change is viewed as possible and in which desires, needs, and hopes can be actualized within and beyond the therapy room.
References:
Miller, W. & Rollnick, S. (2013). Motivational interviewing: Helping people change (3rd ed.). The Guilford Press.
NSA Conference Keynote. [Joze Piranian]. (2023, July 5). Can stuttering and confidence co-exist? [Video]. YouTube. https://youtu.be/ePWoGwLk4W8?si=9hIWwS0LbI50BXGB
Principles of counseling people who stutter. (n.d.). The Stuttering Foundation. Retrieved September 24, 2023, from https://www.stutteringhelp.org/content/principles-counseling-people-who-stutter
Spero Stuttering, Inc. [Ana Paula Mumy]. (2023, August 2). Positive outcomes of effective speech intervention for people who stutter and their families [Video]. YouTube. https://youtu.be/l4pddgtEH3g?si=bf1jRAGXatt6SE8T
Very interesting discussion. Yes I do agree that the ***perspective*** on stuttering is very important.
You write, “An open-ended conversation with a person who stutters can yield the problems associated with stuttering: shame, guilt, embarrassment, fear, anxiety, saying less, staying home, hiding, hopelessness, concealment, unwanted thoughts, diminished self-worth and confidence, dread of conversation, and physical exhaustion.”
What tools do you offer to handle the items mentioned in the above paragraph? Do you believe the Albert Ellis’ statement based on Stoic philosopher Epictetus teaching that “It is not the event (in this instance stuttering) that causes the unhealthy negative emotions of shame, guilt, embarrassment, fear, and anxiety but the irrational beliefs about stuttering that cause these feelings?” And do you think that the consequent behaviors are strongly influenced by the unhealthy negative emotions caused by the beliefs.
What about the hopelessness, concealment, unwanted thoughts, diminished self-worth and confidence, and dread of conversation. Have you hypothesized to the client that his self-talk pattern could play an important part in generating the above?
Or do you think that a client should have in his repertoire stoic philosophy, positive psychology, and Rational Emotive Behavior Therapy tools? Aren’t we sometimes doing the client disservice to expect him to know all of the above when it took me years and earning a psychology doctorate to learn all of this?
I certainly agree that we need to let the client define his area of concern, but like Vygotsky I try to provide the client with “scaffolding” so he can start to build his tool kit to address his problems. And note I do not delimit therapy to “speech problem” only. A complete definition of stuttering in my opinion is much more than that. As you can see in my Facebook pages of my expansion of Dr. Sheehan’s iceberg.
Thank you for reading, Dr. Neiders, and for all the important points you bring! Yes, someone’s core beliefs about who they are (or are not) because of their stuttering certainly impacts a person’s emotional reactions to their stuttering and their subsequent behaviors or actions. The unhelpful self-talk of many clients is often, “Stuttering is bad” or “I should be able to talk by now” or “I’ll never have a girlfriend if I stutter” or “I need to hide my stutter” or “I’ve got to get this fixed.” Any and all of these core beliefs are addressed within the approach we are describing, which generally leads to forward-moving and comfortable speech/stuttering rather than reactive tense stuttering and avoidance behaviors. Mike, for example, is living his life fully (i.e., interacting socially, cultivating relationships, enjoying his job, etc.) WITH his stutter, something he never imagined was possible. I just looked up your version of the stuttering iceberg, thank you for sharing that!
Very interesting article – I am currently taking my stuttering course in graduate school right now and feel as though much of this discussion aligns with what our professor has lectured about.
Your points of ‘meet clients where they are’ were comparable to the discussion of open conversations that we have had in class. Much of what our course covers deals with the idea of understanding a person who stutters problems or the nature of their problems as well as the types of change they desire to make. Our professor often shares therapy session clips where she is really getting down to the nitty-gritty of these problems/desires. As a student with limited experience, I have always been curious how she knows what to ask- especially follow-ups to their answers. Your discussion and examples of probing their experience of stuttering and desired outcomes really made me better understand just how important these expansions are.
Thank you for reading, and I’m glad the examples were helpful to you!
It is encouraging to hear that graduate courses are focusing on the experience of stuttering as a means of assessment and development of treatment plans. Thank you for sharing that.
Regarding “knowing what to ask next,” I can assure you that most of us did not start this way. My own learning came through a combination of formal trainings, reading on counseling, discussions with like-minded colleagues, and most importantly, actually counseling. Some of the best advice I’ve ever heard is that clients will teach us which questions to ask and whether a reflection we have made was accurate. You will likely begin by using other peoples’ questions as a model, become increasingly comfortable with them, and over time, make them your own. At some point, someone will observe your therapy and ask how you knew what to ask. And that is the beautiful cycle of our field.
I thoroughly enjoyed reading this! Thank you for pointing out that meeting our clients where they are currently does not mean to just take the client’s lead no matter the consequences or implications. I think there is a lot of hesitation when it comes to SLPs practicing with solution-focused therapy with stuttering because it is scary to think you have to jump in blindly, thank you for clarifying that it is not the case. And thank you for opening the reader’s eyes to the fact that stuttering is not as black and white as we think (stuttering vs. fluency) there is so much between and beyond those two points that are worth exploring.
(I love the use of analogies, however, I cannot relate to your analogy in this case as I live in New York and our ocean water here is probably just as dark and murky as lake water haha.)
Nicole, thanks for taking time to read and share some clarifying points for you. I love learning what others find helpful. I am terribly sorry about your ocean water, but I imagine you have many reasons keeping you in New York which outweigh the ocean.
Thanks for reading, Nicole, glad it was helpful to you! You need to visit Brazil for beautiful ocean water! 😉
Thank you for your presentation. I am in a graduate program for speech language pathology and I found your words encouraging. In reading some of the submissions I felt a little bit discouraged by their feelings toward SLPs and therapy. I do not want to try and change anyone or make them feel any less than the amazing individual they are, but my eyes have been opened to how good intentions do not always come across as such. In my graduate course we talk about the many different theories, but my takeaway is that stuttering is an individual experience. Your suggestion of meeting clients where they are and your specific examples of what to do and what questions to ask are very helpful. I appreciate your comments above about the evolution of knowing what questions to ask. It gives me hope that one day I too can find myself in my own journey in the beautiful cycle of our field.
Thanks for sharing your feedback and for taking the time, as a graduate student, to educate yourself on the personal experiences of people who stutter. I wish for many more students with your mindset and commitment.
Great article!
Have you ever asked clients who stutter to try disclosing their stutter prior to initiating a conversation or speaking in front of a group? For example, “Hi my name is Sarah and I have a stutter.” Could this possibly help to ease some of the anxiety of aiming to be 100% fluent and allow clients to see that their stutter does not have to control their communication?
Hi Sarah,
Your concern about easing anxiety is an important one. Some may ask whether acceptance simply means they “resign” to stuttering and “passively accept their fate.” Therapy can certainly introduce these kinds of choices (to disclose stuttering, as you suggested) by exploring their options in the situation. One way I have explored this with clients is to ask them, “Have you ever told someone that you stuttered?” If they say “yes,” I ask them to tell me what they said and what happened next. My hope is to find a success somewhere and amplify it. If it is a new concept, we will discuss various ways of disclosing and plan (together) when and where to try this. Some may be ready to try it, while others may need more time building up to it. It touches on what Joseph Sheehan termed role congruence-being the same person inside and outside, or how you present yourself to others. The more “yourself” you can be in your various social spheres, the freer you will be to let go of the control your speech or the listener’s reactions to it. Great suggestion! And I hope this might support further consideration into the topic.
Sarah, the only thing I’ll add to Daniel’s response is that when clients report that they have disclosed their stutter, they often report the freedom that comes from not worrying about what others might think or from anticipating any visible negative reactions from others (because they previously did not realize that person stutters), so it frees them up to focus on their message and to better connect with their audience (whether it’s one person or a group of people). That freedom in “head space” is such a positive outcome!
Hi Anna Paula and Daniel – thank you for this information. I get nervous when these pithy phrases make their way into parent conversations, as hopeful parents make assumptions that are not always accurate. Your paper does a lovely job of getting at the nuance. You are highlighting the need for SLPs to go beyond that rhetoric, explore the options, and attach real meaning to these phrases. It’s important that parents are informed consumers and understand why they need to push beyond these statements and find out what the SLP really means. Obviously “meeting clients where they are” will look different for each encounter – (the point of this whole conference!). Having informed clients is key to minimizing unrealistic expectations and improving outcomes focused on quality of life. Thank you for taking the time to unpack the “meeting clients where they are” phrase!!
Thanks for taking time to read our paper, Dori, and for offering your feedback. I love pulling back the proverbial curtain when opportunities arise and building rationale for change with clients and families. Kids should know what we are working on and why (and so should parents). We are fortunate to work in a field which is increasingly mindful of the language we use and with groups such as yours (Voice Unearthed), parents are able to pull back the curtain for one another as well. Thank you for that.
Thank you for reading and responding, Dori! I completely agree with you…our ultimate goal is improving outcomes focused on quality of life!
I am currently studying stuttering in graduate school. I love hearing and learning more about it because I have not been educated on it as much. Thank you so much for sharing!
So glad you are here seeking to learn more!
I did not have this type of training in my graduate program, either. It’s great that you are taking your ongoing education into your own hands!
I found this article to be very interesting. I love that while you believe that therapy can be helpful, it is still important to remember to keep the client and their wants and needs in mind. As a student, I find it very interesting to see all the different points people bring up when it comes to something as controversial as stuttering. I loved that you decided to dive deeper into what was most important to your clientele and the education they had about stuttering.
Thank you for reading! It’s always so encouraging to see students seeking a deeper understanding of the stuttering experience. Glad you’re here!
Hi Daniel and Ana
The first time I read this, my trauma kicked in and made me upset. Again people telling me that what I want and think is wrong and others are right. I was told this by family members, classmates, teachers, clinicians, and so on. But than I read it again. And found it this is exactly what I preach in all my keynotes, presentations, papers etc: SLPs and PWS sitting together in front of a smörgåsbord. Lots of “dishes”, conventional as well as unconventional, presenting what’s there, what’s in it and what the taste might like, and listening to the client’s expectations, wishes, tastes, and maybe even financially, timely etc. If possible try some “dishes” and see if it is as expected, take some away, and even combine some, just like chefs do to create the perfect taste. And even when chosen, you might want to try something different next time.
So yes, you know therapy, the client knows his stutter and his situation, but listening to each other, there might come up something that is mix of both, or something completely different when getting to know the options and the SLP-PWS better, something just perfect for that very client and an SLP feeling comfortable enough to work with that, or blend in outsiders. Techniques + yoga. ACT + singing. As there should be no boxes, but only perfect recipies. 🙂
Happy ISAD and keep them talking
Anita
Hi Anita, thank you for reading…I’m glad you read it a second time! 🙂
Anita, what a wonderful example of listening you have given. Reading and then re-reading to ensure you understood where where the writer (in this case, us) was coming from. The online world, and certainly the stuttering world, could benefit from more of that. Thank you!