12/25/08

Merry Christmas

Merry Christmas! :)

I was surfing to find something up beat to relate stuttering to this holiday and bumped into a good looking site called http://www.stutteringhub.com . I couldn't find the rap about Christmas on the site, but, some of the links and articles looked informative.

Judy

12/19/08

Desensitization

Speech therapy for stuttering is more than learning new speech motor skills. This is because the actual use of more fluent speech in every day life is complicated by time pressure, language, social, and emotional demands. So, while regular motor practice is essential (practicing 'speech tools'), therapy must consider how fluency changes as a function of what is going on both inside and outside the speaker. These fluency disrupters are somewhat consistent across students; however, speaking situations are very personal, with details that are unique to every case. This blog entry is about one way to manage the emotional demands which make stuttering worse. It is called desensitization.

The purpose of desensitization is to reduce the disruptive power of an internal emotional response. A detailed explanation of self-desensitization can be found at http://www.guidetopsychology.com/sysden.htm . First, the speaker learns how to diffuse physical tension and emotional feelings. Support for this approach comes from such titles as The Relaxation Response by Herbert Benson & Mirian Klipper (Harper Collins, 2000). An example exercise I've observed other SLPs teach is to simply ask a student to make a fist and pay attention to the feelings of tension in his hand and arm. Then, as the student unclenches the fist, he notes carefully how his muscles feel as they relax. Thus, the student becomes aware of what relaxed muscles feel like so as to seek that feeling as needed in the future. I used this technique alot in my younger days while learning to ride horses. I would almost constantly self-monitor muscle tension in order to ride more fluidly and in-tune with the animal.

One goal of the person who stutters is to localize exactly where in the mouth, neck, chest, and anywhere throughout the body, tension increases during stuttering. At first, this tension can feel like just a generalized sense of anxiety and possibly even panic. Some speakers experience quite intense physical and emotional responses in conjuction with stuttering. More about this can be found in an interesting paper by Louise Heite called La Petite Morte: Dissociation and the Subjective Experience of Stuttering at http://http://www.mnsu.edu/comdis/isad4/papers/heite4.html . Some speakers experience enough anxiety to avoid sounds, words, people, speaking tasks, and entire situations. Regardless of the degree to which tension/anxiety exists, desensitization may be helpful.

One way to use desensitization is to find a 'designated listener' who is knowledgeable about stuttering and comfortable with listening to stuttering. The person who stutters is allowed to stutter freely while talking to his 'designated listener.' The designated listener never responds negatively to stuttering, and therefore never fuels feelings of shame and embarrassment in the speaker. This allows the speaker to become more comfortable about stuttering openly. This is why, in my speech therapy, there are times when my students stutter MORE before they stutter less. As they learn to trust my response, they let the stuttering out. This is a major achievement, because then, we can examine what exactly is happening - discover where exactly the muscle tension is that needs to change. Or, alternatively, this can include staying in the moment of stuttering (as possible) in order to desensitize fear, stay in the present, and study the behavior. More about this method can be found at the end of an article by Starkweather & Givens, Stuttering as a Variant of Post Traumatic Stress Disorder: What We Can Learn at http://www.mnsu.edu/comdis/isad6/papers/starkweather6.html .

Another way desensitization is used in speech therapy is to practice relaxation responses in stressful speaking situations. Here, the focus is not so much on the stutter itself, but rather on the internal physical/emotional responses of the speaker and the characteristics of speaking situations. This is when we design hierarchies to represent gradually more difficult speaking tasks. I write hierarchies in the plural, because I've found that they change constantly. The SLP and student may revise a hierarchy at every meeting, tweaking it based upon the student's homework experience. The SLP teaches the student to become a scientist - experimenting, examining, evaluating and creating new hypotheses about how to move toward his own personal goals. This progress is easier when not confounded by negativity, which is why reducing phyiscal and emotional reactions with desensitization is important.

12/17/08

Predicting Success

This blog is about the individual.

1. Page 4 of the Fall 2008 Stuttering Foundation Newsletter reports http://www.stutteringhelp.org/Portals/English/fall_2008_newsletter.pdf included the following concept: "For the field of psychotherapy... on average, treatment is effective regardless of the particular intervention approach used...statistical differences in effectiveness of various treatments are likely to be due to client variability and clinician expertise rather than the specific treatment approach itself." For several years, I have heard the off-handed comment made in workshops that it is the clinician-client relationship, not the specific treatmet method, that best predicts successful therapy. Walter Manning, Ph.D. has presented on this topic, but I am still looking for the reference.

2. My husband brought to my attention a Malcolm Gladwell piece in the December 15 New Yorker Magazine titled Most Likely to Succeed http://gladwell.typepad.com/gladwellcom/2008/12/teachers-and-quarterbacks.html . In this article, Gladwell talks about how difficult it is to judge if a newly drafted quarterback will make it in the NFL, regardless of how talented and successful his college career. Football scout Dan Shonka describes what he looks for in young talent: when a player faces failure, will he "... throw it away and play another day. Will he (the quarterback) stand in there and take a hit, with a guy breathing down his face..." Speech can sometimes be this kind of challange.

Yet, Shonka says that even these qualities do not guarantee success in the NFL and Gladwell describes similarities between scouting for football players and scouting for classroom teachers. With respect to speech therapy, how can consumers predict which SLPs or programs will lead to successful outcomes? I don't think "outcome data" adresses this issue completely. As an SLP, I've learned only to work with clients that I feel benefit from my teaching style. My practice is not like a retail store or even a doctor's office. It consists of carefully chosen clientele that I look forward to seeing and who make consistent progress.

3. I learned this week that a gifted SLP who was a colleague of mine at the Easter Seal Society of Allegheny County in Pittsburgh, PA, has died of cancer. Another is gravely ill. This prompts me to reminisce. I was so fortunate to have worked with such good people when I left college and entered the field of speech language pathology. I didn't know it at the time, but the likelihood of my success in this field greatly increased when I became a member of the Department of Communication Disorders at the Easter Seal Society. The high standards, warm feelings and mutual respect between SLPs nurtured there laid the foundation for my current practice.

It's the people that matter. SLPs must follow best practice, which is now considered "Evidence Based Practice." Consumers struggle with insurance coverage, school district guidelines, and choosing from a host of treatment options. Yet in the end, it is the people that matter. There are many noteworthy, ethical professionals in the field of stuttering. Here are a few of my favorites: John Ahlbach, Alan Badmington, Russ Hicks, Michael Sugarman, Walter Manning, Marty Jezer, Gerald Johnson, Judy Kuster, Barry Guitar, Phil Schnieder, David Ramig, Cheryl Gottwald, Marybeth Allen and Louise Heite. If you Google these names, I predict you will locate high quality information.

12/14/08

Speech & Language Concerns

It is common for my students to experience speech and language concerns in addition to stuttering. According to Kenneth J. Logan, Ph.D., it may be that families of children who have additional concerns are more likely to seek speech therapy. Dr. Logan reports that studies have discovered up to 63% of children identified as stuttering also evidence co-existing impairments of language and/or speech sound production. Even children who appear only to stutter may have other subtle difficulties. "Children who stutter also seem to take longer than nonstuttering individuals to plan syntactic information...there is growing evidence that children and adults who stutter have difficulty executing language-related tasks, particularly difficult or demanding ones, as efficiently as people who do not stutter." For more information, visit http://www.mnsu.edu/comdis/isad7/papers/logan7.html to read Logan's article, When Children Who Stutter Present Co-occuring Speech-Language Disorders: Some Clinical Considerations.

Designing speech therapy activities becomes more complex when the SLP needs to keep in mind a student's articulation, phonology, or language concerns. Traditional stuttering therapy already requires that she create engaging activities that involve speech and language simple enough to increase fluency. When a child has additional concerns, Logan suggests that she has 3 choices:

1. treat both the stuttering and speech/language issues simultaneously

2. treat the stuttering and other issues in a cyclic fashion - treating only 1 issue for a set period of time, then switching to another issue for a set period of time, etc.

3. treat each speech/language concern in sequence - remediating one communication issue first before moving on to another

"Research has repeatedly shown that fluency, articulation, and language skills are interrelated. For instance, the syntactic complexity of a sentence affects how fluently children speak and how accurately they produce consonants. So, regardless of which intervention approach is selected, SLPs need to have a keen sense of how difficult a particular articulation, fluency, or language target is." Logan offers some advice, but allows for the SLP's discretion. The SLP may have a personal preference or collaborate with family and other professionals in this decision making process.

Literacy is one issue I've encountered repeatedly in my practice. I have included many literacy based activities in a casual way, from letter identification all the way up to analyzing narratives at the high school level. The American Speech Language Hearing Association produced a Position Statement in 2001 stating that SLPs "play a critical and direct role in the development of literacy for children and adolescents with communication disorders." Published Guidelines, Technical Report, and Knowledge and Skills documents describe the SLP's scope of practice in the area of literacy. The interested SLP can purchase an ASHA Professional Development course entitled Roles and Responsibilities of Speech-Language Pathologists With Respect to Reading and Writing in Children and Adolescents (ASHA Self-Study 7421) for a detailed introduction to this area of practice.

12/12/08

Voluntary Stuttering?

Voluntary stuttering is a technique that seems to be effective for some persons who stutter (pws). I have a diagram from a newsletter published by the Speak Easy International Foundation (233 Concord Drive, Paramus, NJ, 07652, 201-262-0895) titled Differences Between Involuntary (Real) Stuttering and Voluntary Stuttering. Real stuttering, in this diagram, involves a vicious circle of increased struggle and physical tension. The effects of real stuttering are diagramed as "increased struggle, real stuttering maintained, avoid word or situation, increased fear." Voluntary stuttering, on the other hand, is a circle of reduced physical tension, reduced struggle, and reduced involuntary stuttering. The effects of voluntary stuttering are diagramed as "word or situation completed successfully, increased confidence, reduced fear/tension/struggle and real stuttering diminished."

By the way, Speak Easy is a group that publishes a helpful newsletter, holds weekend retreats, and puts on an annual conference in N.J. I attended once and found it warm and informational. I was privileged to meet the late Marty Jeezer at this conference. I walked up to him quite in awe, shook his hand and introduced myself. He responded in a warm, gentle, friendly way that I would later discover again when he, Cynthia Scace, and I talked to a class of speech language pathology students at the University of Massachusetts. I digress deliberately because Marty was a beloved person in the stuttering community and his book A Life Bound Up in Words is a must-read for adults who stutter. You can read a short piece by Marty at http://mnsu.edu/comdis/kuster/pioneers/mjezer2005/martynsa.html . Also for adults interested in a support group, a Speak Easy event is an alternative to the large scale, roving convention put on by the National Stuttering Association.

Voluntary stuttering is done in a deliberate, gentle and controlled way. It is used primarily on words and sounds that are not feared by the pws. The point is not to induce real stuttering, though this is a risk. The point is to experience disfluency that is relaxed and controlled in order to desensitize to any fears that may snowball into anticipatory anxiety and contribute to avoidance. Peter Reitzes has a paper describing voluntary stuttering at http://www.mnsu.edu/comdis/isad8/papers/reitzes8.html.

Peter also has a You Tube video about speech tools at http://www.youtube.com/watch?v=g8biSBPsoeg

12/10/08

Fluency Enhancing Techniques: Easy Onset

For many years, speech therapy has offered "fluency enhancing techniques" as one way to manage stuttering. Fluency enhancing techniques ('speech tools') are physical behaviors that the Person Who Stutters (PWS) is expected to practice rather religiously in order to establish a new way of talking that involves less struggle and more fluency. The premise is that reactions to the moment of stuttering - sound repeititions, prolongations, secondary behaviors - are learned and can therefore be unlearned. The block itself remains a mystery. That moment when the vocal cords refuse to vibrate - the precise moment of the stuttering block - is not learned, according to speech language pathologists. Current research suggests that this moment is neurologically based. Speech therapy addresses the myriad of behaviors a person does in response to the moment of the block.

Learning a new behavior means replacing an old behavior. In the case of stuttering, this means substituting more relaxed speech for tense speech. We continue to appreciate that stuttering is a puzzling involuntary motor movement. So, while the PWS learns a more relaxed way of speaking, we accept those times when speech is still stuttered. The speech language pathologist trains fluency enhancing techniques and at the same time measures the frequency and quality of this ongoing stuttering. The severity of stuttering should diminish as the PWS uses fluency enhancing skills more often and with more ease. Kay Monkhouse, Ph.D. describes this learning process in an Intenational Stuttering Awareness Day 2007 paper, http://mnsu.edu/comdis/isad7/papers/monkhouse/monkhouse7.html.

Easy Onsets: In my practice, I call this Slow & Gentle Beginning Sounds. It is sometimes called Easy Relaxed Approach Smooth Movement, Light Contact, Easy Speech...The point here is that the PWS learns to talk by saying the beginning sounds of words with very relaxed and slowed articulation. Why? Because it is at the beginning of words that most stuttering takes place. In addition, rushing through the articulation of sounds is a common behavior of PWS. First, it is practiced in a variety of single words, especially words beginning with sounds that the PWS fears he will stutter on. Next, it is practiced in phrases, where only the first word of a phrase is pronounced gently and slowly. Finally, phrases are combined to create sentences and it is at the phrase boundaries that this slow/gentle pronunciation is used. Stuttering is most likely to occur at the beginning of phrases because this is where there is often a pause in voicing. Starting up the voice, initiating vocalization, is a key problem for PWS. While practicing this way of speaking can sound very stilted at first, I have heard many adult PWS master this speaking style in a way that sounds quite natural. For others, their speech may sound different from fluent speakers, who tend to speak very rapidly and without consious awareness. However, the new style of speech provides a greater sense of control and greater fluency than previously known.

I will continue with additional techniques in future posts.

12/6/08

It's the Journey that Matters

Reflecting upon another Saturday of speech therapy, I marvel at how the day is planned yet unpredictable. The longer I work as a stuttering specialist, the easier it has becometo let go of detailed lesson plans and allow each session to evolve in its own unique way. My lesson plans are now guidelines that structure the first 15 minutes of a session and act as an invitation for the client to talk about his goals - in that moment of time. Together, a loosely structured interaction begins in which constant give-and-take results in useful work accomplished in only 60 minutes.

The lesson plan is nearly sacred to the student of speech-language pathologist. A few summers ago, I supervised a student from Boston University who was earning her Masters Degree and had a special interest stuttering. She wrote lesson plans with specific goals and descriptions of therapeutic methods that would be used to help her clients achieve those goals. The university required that she write extensive evaluations of her sessions when they were done, presumably in order to prepare the next set of lesson plans. Whew!! This kind of preparation was fine at the start of my career. But now, I find this approach often ignores the reality that each client has lived for days, weeks and sometimes months between each speech therapy session. The slp needs to know what's happened in that space of time that might affect what kind of work the student is ready for next.

Yet, there are important long-term goals and methods to keep in mind. E. Charles Healey, professor of speech pathology at the University of Nebraska, penned a two-part series called Seven Principles of Stuttering Therapy http://www.mnsu.edu/comdis/isad10/papers/healey10.html and www.mnsu.edu/comdis/isad11/papers/healey11.html which addresses this. Let's take Principal 4 as an example. How can the slp and client work for increased fluency while accepting stuttering at the same time? I attempted to accomplish this goal in 3 different ways with the 3 clients I saw today.

1.) A teen spent some time reading aloud because he sometimes needs to read aloud in school. I ask if he is choosing to practice with fluency enhancing techniques and, if so, which ones. I ask for a self-evaluation of his reading. But, most of all, I comment on the content of what he has read, not the fluency. I accept the mild persistent stuttering. And I tell him that he reads very well - which he does. He leaves having written 3 "change cards" with goals he came up with on his own.

2.) With a new client, one of the first things I do is demonstrate stuttering. Because I am a fluent speaker, I seldom experience that frightening loss of control that can accompany real stuttering. Nevertheless, my message is that stuttering is just fine by me. As a knowledgeable listener who has accepted the intractable nature of stuttering, I can suggest a plan based on principles of speech therapy.

3.)With an elementary school child, there is time at every session to talk about home and school, regardless of stuttering. When we get to work on a particular fluency enhancing technique, the rewards are not for fluent speech. Rather, they are for consistent use of a chosen technique. Today he earned an outstanding reward for extra-ordinary focus on his goals - even though there were still times when he stuttered. We accept the stuttering. With this acceptance we can move forward to learn new ways of talking without fear or shame.

Change takes time, energy, and flexibility. During one of the International Stuttering Awareness Day Online conferences, I asked the "Professor Is In" for an easy-read about change for clients to understand the process and remain motivated. The recommendation was Changing for Good by James O. Prochaska, Ph.D., John C. Norcross, Ph.D., and Carlo C. DiClemente, Ph.D. (Avon Books, 1994). Sure enough, this book talks about the long term process of change, primarily for adults. The concepts in this book are only recently being researched in the field of stuttering.

The process of change is a journey. A journey requires a map (or GPS). Speech therapy can influence that map by offering information and guidance. But the client is the traveler. The traveler chooses when to move, when to rest, when to pause and appreciate the view.

12/3/08

Stress

Stress is an important topic in speech therapy for stuttering. Some children, teens and adults who stutter discover that stressful thoughts, feelings and situations can change the way they stutter. It is within "the scope of practice" of a Speech Language Pathologist to talk about the basics of what stress is and how a family might begin to reduce stress in their lives. These discussions can be guided by a student's interests, for example, many paperback books related to sports will address how players cope with the stress related to performance anxiety.

In the book Hockey Tough: A winning mental game by Saul L. Miller (Human Kinetics, 2003), Mark Messier writes in the Foreword, "To be consistently successful, he (the hockey player) must be able to summon the energy, courage, and will to complete game after game and to maintain focus and composure in the heat of a real physical battle." The title of chapter 4 is Controlling Emotions. This chapter teaches the hockey player a "simple breathing process that is basic to emotional control and right feelings." (p. 49) When I read: "Part of managing feelings has to do with being able to release feelings such as tension and negativity. Fear is the great limiter..." I can't help but think that this sounds like stuttering therapy. For persons who stutter, speaking can require energy, courage and will. And so, some persons who stutter may find that the advice of sports professionals applies to speaking situations. Whether the client's goal is more fluency, less avoidance, increased self-confidence or other communication skill, successful role models in a variety of life arenas, can offer helpful guidance.

It's not rocket science - fear is an integral part of stuttering. "People who stutter can build up intense fears in response to the loss of control that they feel or in response to the penalty that they experience from listeners. Avoidance behaviors may constitute the largest group of behaviors developed in response to fear. People who stutter will do a variety of things to avoid..." (http://www.d.umn.edu/~cspiller/stutteringpage/phenomenology.html).
The stress resulting from fear can be paralizing and lead to avoidance, or, it can be energizing and lead to assertiveness. Publications about stress management can be found on-line and in any bookstore or library. For teens, I recommend Fighting Invisible Tigers: A Stress Management Guide for Teens by Earl Hipp (Free Spirit, 1995). A humorous quick read for adults is the thin book How to Stay Stressed, by Douglas Stewart (InWord Press, 1994).

An SLP can guide a conversation to assist a teen, adult or family list and prioritize new ways to go about managing stress as it relates to stuttering. Improving quality of life, not just increased fluency, is a valid goal of speech therapy. However, other professionals are more qualified to deal with serious emotional, psychologial, or medical issues that may also be creating stress for the person who stutters. It is the client's responsibility to pursue the topic of stress reduction outside of speech therapy. Improvements in diet, exercise, social support systems, medical status, and mental health can all contribute to a lifestyle that supports more effective communication.
Creative Commons License
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.Creative Commons License
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.