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A PRACTITIONER'S VIEW OF STUTTERINGDavid A. DalyDavid
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 -
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