Providing an overall positive therapy experience!
Hi Everyone!
I am a speech pathology graduate student who is very interested in learning more about stuttering as I have not yet had a client who stutters, but I am longing to work with those who stutter. I am currently enrolled in a stuttering class and it has really grasped my interest in working with those who stutter. I was hoping to gain insight from professionals, What is the best way to counsel and create functional goals for patients who stutter and who may not have the desire to attend therapy or practice techniques to help their stutter? As we have learned in class all goals should be individualized, but for example, what if the child is attending therapy for their stutter because of a parent’s decision but does not have any desire to attend therapy? I recently listened to a podcast where an individual did not have a positive experience in therapy and it really opened my eyes to all careful decisions I would need to consider when working with a person who stutters. Also, are there any difficult decisions or challenges you as professionals have faced that would be a good learning experience you’d like to share?
Hi Anna-Leah!
Thank you for your post and wonderful questions!
Graduate school is such a fun and exciting time! For me, graduate school was when I also realized my interest and passion for working with people who stutter. I don’t think I’d even thought about working with this population until then. My first client who stuttered was a girl in elementary school. She didn’t talk to me for the first several sessions and I remember feeling lost and not knowing what to do. I remember trying to think about all the different “techniques” that I’d learned in class. I left her sessions feeling as though I’d failed as a clinician until one of my supervisors pointed out to me that during the session the girl had been laughing, smiling, and enjoying herself. That moment for me was a huge turning point. I realized that therapy sessions are so much more about connecting with our clients than trying to “fix” them. Through conversations and time spent together, we can learn about our clients – their likes, dislikes, hopes, dreams, values, and goals (for themselves and their communication). These conversations are really important in helping us to guide our clients toward what they want to get out of therapy (which often may have little to do with an actual moment of stuttering).
Through my experiences working with people who stutter, I’ve also learned the importance of looking at communication as a whole – not just focusing on those moments of stuttering. We are all working to grow and evolve as communicators and that is a journey we can walk on with our clients. Our clients have so much to teach us – and I think you will find that you tend to learn way more from them than they will learn from you!
You bring up a really important point when you talk about making the goals functional for our clients. Again, this is where that conversation comes in. Talking with your clients about their goals for their communication. I often ask my clients to rank various speaking situations in their lives from easy to hard. Then we talk about what makes those speaking situations hard. I’ll then have my client pick one or two of the speaking situations that are the most important to them to work on. Those speaking situations then become the client’s goals. We talk about what they want to work on within those speaking situations and we come up with a series of small goals to work towards a large goal. This way, therapy is relevant to the client and is making a direct impact on their daily life. I have clients working on becoming more comfortable introducing themselves to others or working on telling jokes to friends using pausing and more consistent eye contact. These are speaking situations that occur in their daily life.
You will definitely have times in which your client feels that they are only in therapy because their parents want them to be. In these moments, it’s really important to have a conversation with your client and their parents (separately, if possible, and then together) about questions, concerns, goals, etc. A lot of times clients and parents may have different goals and also needs when it comes to therapy. Parents may need a space to talk about their fears, worries, and questions when it comes to stuttering. They may want guidance in feeling like they can ‘do’ something to support their child – and you can help them to see that they are doing a lot by listening and supporting their child. And, you can also assure them that you are always there as a resource and that their child has the freedom to restart therapy at any point if they feel like it is needed. Many clients may come in and out of therapy – on an as needed basis.
These are just some beginning thoughts and ideas! Feel free to ask any follow-up questions you may have. I know you’ll get a lot of other great thoughts and feedback from the other professionals as well!
Best of luck!
~Jaime Michise
Hello Jaime! It is good to reconnect with you here. What a thoughtful reply. I know that you and I share a similar, comprehensive approach to stuttering therapy, and I agree with almost everything you have written here. However, I am wondering about your observation that what clients want out of therapy may often have little to do with an actual moment of stuttering. That is not my intuition, or my experience, either as a person who stutters, or clinician. I am wondering if maybe I am missing something and not fully understanding what you mean here. I suspect this is the case. I would welcome an opportunity to dialogue with you about this.
I am sure that you and I would agree that there is more to stuttering than just stuttering. As clinicians, we need to consider not just fluency and interruptions in fluency, but also thoughts, feelings, and attitudes associated with stuttering and communication; reactions of tension and struggle; patterns of avoidance; various aspects of overall communication competence; and other contributing factors. However, at the end of the day, the actual moment of stuttering seems to be of paramount importance. For adolescents and adults, and even some school-age children, it is the moment of stuttering – and anticipation and fear of the moment of stuttering, and panic (fight/flight/freeze) during the moment of stuttering – that we most need to address in stuttering therapy (of any kind). If not for the anticipation and fear of the moment of stuttering, panic during the moment of stuttering, and reactions to all of these phenomena, there would be little to address in therapy. If I have run off the rails, I would be happy to have you course correct for me. Warmest regards,
Rob Dellinger
Hi Rob-
It’s great to hear from you – and to reconnect! Thank you so much for your post – and question! Let me clarify what I meant as I may not have been as clear as I’d hoped in my response. Sometimes, I think a lot of focus can be placed on a person’s primary stuttering behaviors only. And, at times percentage of syllables stuttered may be the only calculation used to measure progress in therapy. However, I think we both can attest to progress in therapy being so much more than that! Like you mentioned, stuttering is so much more complex that just the repetitions, prolongations, and blocks. That, in fact, was the exact point I was trying to make in my post. As clinicians, I believe that is imperative that we allow our clients to explore and talk about their stuttering and all that accompanies or arises from those moments of stuttering. By developing an understanding of the big picture we can better help guide our clients toward their goals in therapy. However, if we focus solely on those physical behaviors of stuttering, so to say, we may be missing out on a lot!
I hope that provides some clarification to my post. Please let me know if you have additional questions or thoughts!
Best,
~Jaime Michise
Jaime, thank you for the clarification. As I suspected, it turns out that you and I are squarely on the same page. I agree that progress in stuttering therapy encompasses so much more than just percentage of stuttered syllables. In fact, for many of our clients, I think %SS may be the least important measurement. In my experience, therapy focused solely on fluency, and measured only by %SS, seems less like therapy and more like an evaluation of the surface behaviors of stuttering. As we know, there may be much to address below the surface.
I cannot agree more that effective therapy allows clients “to explore and talk about their stuttering and all that accompanies or arises from those moments of stuttering.” Well said. To expand on that idea, our mutual friend Rita Thurman provides some excellent therapeutic examples in her essay, “Don’t Banish the Dragon” (https://westutter.org/wp-content/uploads/2016/11/Dont-Banish-the-Dragons.compressed.pdf), which I would like to share with readers of our posts. Rita notes that she is often asked, “Isn’t ‘fluency’ the primary goal? Actually, it is not. I like to think of it as changing the reaction to the stuttered moment. Instead of pushing through a block, release it. Instead of avoiding a feared word, recognize that it is scary and say it anyway. Instead of thinking of five ways you could replace that word or a way to rearrange the sentence so the word falls before a vowel so that it is easier to ease into it, use that cognitive power to focus on the sensation of moving forward through the word.” For clinicians who may not be familiar with this kind of approach, I think these are excellent examples of ways to explore working with the moment of stuttering.
Thank you again for taking the time to clarify your post. Best,
Rob Dellinger
Anna-Leah,
Rob and Jaime have given some great input regarding how to focus on the broader aspects of communication and address goals that are important to the client. That is such important information to take into consideration when you have a client who is not particularly interested in addressing their stuttering. Jaime noted that working on skills relating to communication in situations that are important to the client will go a long way to connecting with the client where they are currently.
I would like to share an example of specific client with whom I worked that may help to illustrate this. I worked with a 9-year-old boy some years ago. He was quite angry about his stuttering and indicated that he had no interest in working on his stuttering. He was crazy about basketball, so we spent quite a few sessions shooting baskets. Eventually, I asked if it would be OK if I practiced stuttering as we played. He agreed that this would be OK. Eventually, he said he thought he could stutter better and more than me. Let the contest begin! Eventually, he was laughing and stuttering up a storm, and more importantly, talking freely during our games. Eventually, he would engage in short conversations about stuttering. He was able to talk about stuttering and put it in his mouth on purpose, whereas before this, he barely spoke at all. His father put a lot of pressure on this child to ‘do something to talk right’, so eventually, we invited dad to shoot baskets with his son and engage in stuttering while doing this. Of course, the child beat his dad hands down as far as stuttering, which did a lot to boost this child’s confidence in interacting with his dad. Being open to doing things differently to build a relationship with your client can lead to positive changes in communication. In fact, it is so important to keep this in mind when working with clients who are motivated, as well.
I wish you all the best as you complete your graduate training.
Regards,
Lynne Shields
Hi Anna-Leah – You’ve asked some nice questions, and my colleagues have offered you excellent thoughts up above.
The piece that I want to address is the issue of what a child might work on, esp. if he’s not invested in the therapy. This is actually the case, all too often. Parents want children to work on their speech even if children don’t experience stuttering as a significant problem at different points in their lives.
I address this in two ways: First, I look to see if the child is experiencing any adverse impact in his life as a result of the stuttering. If he is, then I focus on minimizing that adverse impact as my “hook” to the child’s interest in and motivation for therapy. (For example, let’s say a child doesn’t have any interest in learning strategies for fluency, as the parent might wish for him to do. But, he has expressed to me through testing and interview that he isn’t able to tell a joke with his friends as easily as he would like. Well, I’ve just found HIS motivation: telling a joke. I think focus the therapy on helping him learn to tell jokes more easily. The path to doing that might involve techniques; the rationale for doing it is now more palpable for the child.) So, adverse impact assessment is where I would start.
Second, though, if the child does NOT have any adverse impact, and if I can document this (I use the OASES for this), then my focus turns toward helping the parents learn more about stuttering so they can see that it is okay for the child to stutter and that he does not have to be in therapy at that point just because he stutters. We treat kids (in the schools especially ) to minimize adverse impact – and it is that adverse impact that forms the basis for the child’s motivation in therapy. Without adverse impact, there is no reason for a child to work on his speech. Why would he, if he’s fine?
I addressed this topic in a blog post recently for Stuttering Therapy Resources. You can find it at http://www.StutteringTherapyResources.com/blog
Hoping this helps,
J Scott Yaruss