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Oakland County Speech-Language-Hearing Association

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A PRACTITIONER'S VIEW OF STUTTERING

David A. Daly

David A. Daly is director of Speech and Language Pathology Associates; a private practice in Livonia, Michigan, and associate professor of speech and language pathology at the University of Michigan, Ann Arbor. (This article was peer-reviewed.)

    As a speech-language pathologist with a thriving private practice specializing in stuttering, I have changed my theoretical and clinical perspectives about the treatment of stuttering considerably over the last few yearn. Rather than adhering to a specific program, I now use a combination ot motor-training, positive mental imagery, and self-instruction techniques with most clients who are chronic stutterers. I agree with Van Riper’s (1971) statement that "clinicians must deal with more than the speech of stutterers" (p. 213).

In addition to the significant role of client motivation in the therapy process, three variables stand out as crucial for successful treatment of stuttering: 1) the attitudes and expectations of the clinician; 2) the value of committing to a plan and schedule; and 3) supplementing speech treatment procedures with cognitive and self-instructional strategies.

 THE CLINICIAN'S ATTITUDES AND EXPECTATIONS

The clinician’s attitudes toward stuttering and people who stutter have as much to do with the successful treatment of this disorder as the methods selected for therapy. Clinical experience has convinced me that the clinician must believe in the client, just as the client must believe in the clinician.

The words we choose, and the way we say them, in answering even our clients’ simplest questions have clinical implications. For example, our response to “Can my stuttering be cured?” is never a simple “No.” Instead, we explain that no pill or therapy’ exists which will guarantee a cure. I, however, quickly add that our current treatment programs are helping those who are chronic stutterers to communicate more efficiently and effectively. I point out that some people who stutter do indeed become fluent; others achieve higher levels of fluency control although they may still stutter periodically. Some clients continue to speak in a predominantly disfluent manner, but we strive to help them speak as effectively as possible. That is our goaL—to help each client develop the best fluency possible.

Some colleagues have asked whether we are promoting false hopes in our clients who stutter. I think not. An insightful book on terminally ill cancer patients suggests that “a positive attitude toward treatment was a better predictor of response to treatment than was the severity of the disease” (Simonton & Simonton, 1978, p. 82). This view has been advocated by other clinicians. Mowrer (1960), for example, maintained that hope is absolutely necessary if any learning is to be accomplished. Since we cannot predict which clients will make significant improvements in their fluency and which will not, I avoid making specific predictions about future gains. Instead, I am positive and enthusiastic with every client who stutters. I would rather err in the direction of optimism than pessimism.

I stuttered until my mid-20s. I was turned down for jobs because of my speech. Stuttering clients whom I was treating as part of my graduate school training complained to the clinic director that my stuttering was worse than theirs. They requested (and got) a more fluent clinician.

Fortunately, I received help from a sensitive and sincere faculty member who did not prejudge my potential for fluency. That clinician’s attitude was a turning point in my quest for fluency. Thus I have a personal investment in urging clinicians to be positive, patient, and persistent with their stuttering clients.

Al least one reviewer of the psychological literature dealing with the client’s attitudes toward and expectations of therapy maintains that the effectiveness of therapy is closely linked to those expectations (Lazarus, 1971). Lazarus contends that the client enters therapy with preconceived ideas about the treatment and if the procedures do not make sense to the client, therapeutic impasse is likely to result.

Could a similar phenomenon occur in speech-language pathology treatment for the person who stutters? Might our clients detect any insecurities or uncertainties in the clinician’s attitudes or feelings about the treatment advocated? Clinical experience repeatedly demonstrates that intelligent persons will expend effort and energy in treatment only when they expect substantial results. When the clinician concentrates on negative behaviors or problems rather than positive objectives, clients are apt to get discouraged. Such incongruity between the clinician’s expectations and the client’s expectations may account for the high dropout rate among our stuttering clients. Roughly one-third of stuttering clients withdraw from treatment prior to completion (Martin, 1981). We have expended tremendous effort studying clients who stutter. Perhaps it is time we study ourselves.

COMMITTING TO A THERAPY PLAN AND A SCHEDULE

The clinician should select one of the data-based treatment programs described in our literature and adhere to it. I recommend sticking to a treatment plan for a minimum of i6 sessions (Daly, 1984). Successful treatment of chronic stuttering takes time.

We favor the fluency-enhancing programs which teach components or targets of fluent speech behavior. For some clients, however, even the most basic task may need to be simplified. For example, not everyone automatically shifts to a deliberate, slower, more-fluent manner of speaking when talking on a delayed feedback machine. Some clients need repeated modeling or practice in producing the drone-like’ speech. Many people who stutter try to use the highly pHonated, drone-type speech without decreasing the number of words in their sentences. Droning expends so much air that some clients can not complete their sentences without straining or taking a second breath. This recurrent faulty pattern is remedied by using structured therapy materials requiring shorter segments of speech.

All clients (even people in their 40s and 5Os) initially practice lists of word-pairs. The first few lists contain no plosive phonemes (e.g., "man-fan" or "know-show"). Controlling the length of utterance allows close monitoring of breathing patterns, smooth onset of speech, and continuous phonation (droning). Enthusiastic feedback is given for correct productions. I insist on a 95% success rate on two-word productions before three-word lists are introduced. Again, specially designed lists are utilized (e.g., "foam-home-roam”; "you-flew-through"). The objective is to provide hundreds, perhaps thousands, of opportunities for the client to perfectly execute correct breathing, voicing, and speech onset patterns. When a criterion of 95% is reached, conversation is introduced. Here again the length of utterance is controlled, Initially, no sentence from either the client or the clinician exceeds tour words. Performance of 95% or greater enables the client to move to structured reading material with sentences of five or six words.

Repeated failures have taught me that treatment once a week is unrealistic for most people who are chronic stutterers. I advocate treatment at least twice a week. I feel so strongly about the schedule that I will

The quality of practice is as important as the quantity. fluency skills must be executed precisely, and the correct performances must be accurately reinforced. Clients should not be sent out on assignments before they had had enough therapy to deliver the desired performance (Sheehan, 1980). Role-playing and periodically seeing two clients together facilitates transfer of newly acquired speech skills.

SUPPLEMENTING SPEECH TREATMENT: COGNITIVE AND SELF - 

INSTRUCTIONAL STRATEGIES

Too many of our clients get fluent in their mouths but not in their heads. Despite success, they feet threatened and helpless when trying their new skills alone. I have found mental rehearsal, guided relaxation, and positive mental imagery activities extremely valuable. Before clients can change, they must first see themselves in a new role (Maltz, 1960). Imagining the achievement of a goal actually facilitates achieving it in reality (Lazarus, 1984). Combining relaxation and mental imagery techniques has been effective in confronting and altering cancer patients’ feelings of hopelessness and helplessness (Simonton & Simonton, 1978). Teaching positive self-talk behaviors leads to greater treatment efficacy, more generalization, and longer persistence of treatment effects (Meichenbaum & Cameron, 1974).

I have tried each of these strategies with people who are chronic stutterers.  All have been successful with some clients, but not every technique works with every client. I advocate a combination of techniques. In my view, the value of helping clients picture themselves as fluent in future speaking situations cannot be overestimated. Before clients go out on speaking assignments, we instruct them to practice imagery activities at home. I have designed rating sheets for them to record the clarity of their images. With repeated practice most clients report picturing themselves more clearly. I then instruct them to continue imagery assignments by focusing on the sound of their fluent voice. Our goal is to change the image from visual to auditory. Finally, I ask them to sense how the new fluency feels.” The goal is to accentuate the speaker’s awareness to more than one sensory modality. Interested readers are referred to Lazarus (1981) discussion of multi-modal therapy.

 SUMMARY

In private practice (perhaps more than in other clinical settings), the proof is in the pudding. If your procedures do not produce the expected outcome, you are not in practice very tong. My experience suggests that clients who stutter are helped to communicate more effectively and more fluently by combining speech treatment strategies with cognitive and self-instructional procedures.

 References

Daly. 0. A. (1984). Treatment ot the young chronic stutterer: Managing stuttering. in P. F. Curiae and W. H. Perkins fEds.), Nature and treatment of stuttering: New directions. San Diego:College-Hilt Press, Lazarus, A. A. (1971). Beha dot therapy and beyond. New York: McGraw-Hill Cc.

Lazarus, A.A. (1984) In the mind’s eye. New York: Guildtord Press, Inc.

Lazarus, A. A. (1981). The practice of multi-modal therapy. New York: McGraw-Hill Co.

Main, M. (1960). Psycho-Cybernetics. Englewood Cliffs, NJ: Prentice-Hall, Inc.

Martin, P. P. (1981). Introduction and perspective:Review of published research. In E. Boberg (Ed.), Maintenance of fluency. New York:Elsevier.

Meichenbaum, 0., & Cameron, P. (1974). The clinical potential of modifying what clients say to themselves. Psychotherapy: Theory, Research, and Practice. 11,103-117.

Mowrer, 0. H. (1960). Learning theory and behavior. New York: Wiley.

Sheehan, J. G. (1980). Problems in the evaluation of progress and outcome. Seminars in Speech, Language, and Hearing. 1, 389-401.

Simonton, 0. C., & Simonton, S. M. (1978). Getting welt again. New York: Bantam Books, Inc.

Van Riper, C. 0871). The nature of stuttering. Englewood Cliffs. NJ: Prentice-Hail, Inc.

APRIL 1988  ASHA 

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