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How . . . I manage stammering in adults.

How . . . I manage stammering in adults.

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Getting to know you.
Wright L. (2002)
Stammering therapy is a long-term process of change that may impact on many areas of a stammerer's life. The first of three articles on this topic examines questions of the client's readiness to accept change, the support available in the workplace and home, and the best treatment approach(es) for that individual. These are explored with the client in an initial semi-structured interview, the Wright and Ayre Stuttering and Self-Rating Profile (WASSP, 2000), and these may be followed up later with other personality and attitude assessments. At the end of the first meeting possible therapeutic options which will help clients to achieve their aims are described, including the three main approaches: Van Riper, Conture, and Sheehan. WASSP is used to monitor progress. The aim in all therapy is to empower clients to manage their stammer long-term by helping them to acquire understanding, therapy tools and confidence to cope with changing needs and circumstances.

Tipping the scales.
McNeil C. (2002)
What does a stammer mean for an individual? And what inner resources do they have which will guide therapy? This article describes a range of approaches, particularly neurolinguistic programming and brief therapy which can bring about change. Striking a balance between identifying the problems and looking for solutions early on in therapy is important, avoiding to much analysis too soon. Using brief therapy scales helps to set goals, and using neurolinguistic programming in a supportive environment helps to soften the impact of addressing negative memories and feelings.

Fighting fire with fire.
Bligh A. (2002)
Rather than looking for a non-existent cure for stammering, the Starfish project offers small, intensive three-day courses and unconditional support to recovering stammerers seeking effortless speech. This article describes the nature of the courses, which involve small groups of people (around 10) working for the most part on a one-to-one basis in an intensive, residential setting. Diaphragmatic retraining is employed, as well as long-term rebuilding and adjusting of the plans of the stammerer which will have been designed around word, situation and relationship avoidance. Social support for rebuilding is provided through a nationwide phone list of recovering stammerers available day or night, local Starfish support groups, group supported practise in real life situations, and the option to come back on any course at any time to refresh. Speech and language therapists are welcomed, and many have attended the course and learned the techniques and are able to offer advice and backup to clients who attend the courses.
Getting to know you.
Wright L. (2002)
Stammering therapy is a long-term process of change that may impact on many areas of a stammerer's life. The first of three articles on this topic examines questions of the client's readiness to accept change, the support available in the workplace and home, and the best treatment approach(es) for that individual. These are explored with the client in an initial semi-structured interview, the Wright and Ayre Stuttering and Self-Rating Profile (WASSP, 2000), and these may be followed up later with other personality and attitude assessments. At the end of the first meeting possible therapeutic options which will help clients to achieve their aims are described, including the three main approaches: Van Riper, Conture, and Sheehan. WASSP is used to monitor progress. The aim in all therapy is to empower clients to manage their stammer long-term by helping them to acquire understanding, therapy tools and confidence to cope with changing needs and circumstances.

Tipping the scales.
McNeil C. (2002)
What does a stammer mean for an individual? And what inner resources do they have which will guide therapy? This article describes a range of approaches, particularly neurolinguistic programming and brief therapy which can bring about change. Striking a balance between identifying the problems and looking for solutions early on in therapy is important, avoiding to much analysis too soon. Using brief therapy scales helps to set goals, and using neurolinguistic programming in a supportive environment helps to soften the impact of addressing negative memories and feelings.

Fighting fire with fire.
Bligh A. (2002)
Rather than looking for a non-existent cure for stammering, the Starfish project offers small, intensive three-day courses and unconditional support to recovering stammerers seeking effortless speech. This article describes the nature of the courses, which involve small groups of people (around 10) working for the most part on a one-to-one basis in an intensive, residential setting. Diaphragmatic retraining is employed, as well as long-term rebuilding and adjusting of the plans of the stammerer which will have been designed around word, situation and relationship avoidance. Social support for rebuilding is provided through a nationwide phone list of recovering stammerers available day or night, local Starfish support groups, group supported practise in real life situations, and the option to come back on any course at any time to refresh. Speech and language therapists are welcomed, and many have attended the course and learned the techniques and are able to offer advice and backup to clients who attend the courses.

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Published by: Speech & Language Therapy in Practice on Jul 04, 2013
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1. Assess overt and covert behaviours, reactions and coping strategies.2. Adapt to individuals, using a mix of approaches and time-scales.3. Highlight the strengths and resources clients have within themselves.4. Shift a client’s focus from cure to maintainable progress.5. Pace the flow of information.6. Use rating scales as therapy tools and outcome measures.7. Ensure techniques can be incorporated in real life.8. Empower clients to manage their own communication over time.9. Let clients know it is OK to have set-backs and to return for help.10. Take opportunities to share skills with non-NHS ventures.
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SPEECH & LANGUAGE THERAPY IN PRACTICE
SUMMER 2002
25
how I
I manage
stammering inadults
Stammering in adults and The McGuireProgramme have received a great deal of publicity recently through Gareth Gates fromtelevision’s Pop Idol Although Gareth himself has inspired many young people withcommunication difficulties it is debatable howmuch the nature of the media exposure hasincreased understanding and acceptance of stammering  in people with a stammer as wellas in the nonstammering publicHas the message got across that stammering isa multifactorial and complex phenomenon?That there is no known cure? That people havethe right to be heard whether or not theystammer? Most importantly do people nowappreciate that the management of stammeringin adults needs to be holistic and tailored to anindividual’s needs and wishes  and that ‘overcoming’ a stammer means differentthings to different people? Three people whounderstand this more than most sharetheir experiences
Louise Wright, formerly of theManchester MetropolitanUniversity, is now specialist  speech and language therapist in dysfluency and Sure Start Lescudjack with West Cornwall Primary Care Trust.Claire McNeil is a specialist  speech and language therapist in dysfluency with SwindonPrimary Care Trust. Anne Blight started training asa speech therapist but, feelingthere was not enoughin-depth work for stammerers,got involved as a volunteer instead. Excited by the potential of diaphragmatic retraining - but disillusioned with the way it was beingintroduced in the UK - shefounded the Starfish Project in1998 as a non-profit makingventure aimed at helpingadults and young peoplerecover from stammering.
if you want to• offer therapy tailored toindividualsbe positive and realisticabout prognosisequip clients to managetheir own communication
Read this
 
SPEECH & LANGUAGE THERAPY IN PRACTICE
SUMMER 2002
26
how I
have worked with people who stammer (of all ages) for thepast 22 years and find it as enjoyable and challenging now aswhen I first started. I worked for 11 years in the NHS, latterlyas a specialist in dysfluency, moving on to teach disorders of flu-encyat undergraduate and postgraduatelevelsat the ManchesterMetropolitan University. Whilst there I also ran a weekly special-ist dysfluency clinic supervising students, and carried out researchinto employment and family issues for adults who stammer.I have worked with adults who stammer individually, in weeklygroups, in the workplace involving managers and colleagues, inintensive groups and also on residential intensive coursesinvolving families and friends. Anne Ayre and I developed TheWright and Ayre Stuttering Self-Rating Profile (WASSP, 2000) asan outcome measure for therapy with adults who stammer as aresult of our work with adults in the workplace (Ayre et al,1998) and I use this as a tool both to plan and evaluate therapyoutcomes.My approach to therapy is influenced by a number of over-archingprinciples. I always work with the client’s stammer within thecontext of him or her as a person. I adapt my approach to suittheir personality, lifestyle, impact of their stammer on their life,experience of past therapy and their readiness for change(Prochaska & Di Clemente, 1986). I do this by taking time to getto know them, listening to them and involving them in therapydecisions by explaining possible options, experimenting andevaluating the results. I see stammering therapy as a long-termprocess of change that may impact on many areas of their lives.
Exploratory
I begin to understand them and their stammer through an ini-tial semi-structured interview (severity of the stammer permit-ting) and I may follow this up later with additional exploratorytools such as the S-24 Attitudes to Communication Scale(Andrews & Cutler, 1974), Locus of Control of Behaviour Scale(Craig et al, 1984) and Self-Characterisation (Kelly, 1991).I always aim to address the overt and covert aspects of the client’sstammer, their reactions to stammering and their current copingstrategies. I use WASSP to explore the following aspects of their stam-mer and to obtain a baseline self-rating measure from which we canmeasure change following a block of therapy. WASSP includes:Stammering behaviours including frequency of stammers,amount of physical struggle or tension during stammers,urgency or fast speech rate, associated physical movements madeas a reaction to stammering, general level of physical tension,eye contact and any other behaviours which are significant.Negative thoughts about stammering before, during andafter stammering.Feelings about stammering such as frustration, embarrassment,fear, anger, helplessness.Avoidance as a coping strategy at the levels of words, situations,talking about stammering with others and admitting theirproblem to themselves.Disadvantage experienced at home, socially, educationallyor at work as a result of their stammer.I will usually ask the client to complete WASSP at the end ofthe initial interview when they have spent some time reflectingon and discussing aspects of their stammer which they may nothave considered for some time, if ever. The client at this pointrecords their aims and expectations of therapy.Use of WASSP also helps me to illustrate which areas therapy willaddress and where they may expect change to occur. Some clientsare surprised that I am not just going to address the mechanics ofspeech. Others are relieved that I understand the complex multidi-mensional nature of stammering and will be helping them toaddress it on many levels. For many it is the first step in under-standing their stammer and how therapy is going to work.At the end of the first meeting I will describe possible thera-py options that will help them to achieve their aims. If they
Gettingto knowyou
Stammeringtherapy is alongterm processof change that mayimpact on manyareas of astammerer’s lifeBut is your clientready to change?Do they havesufficient supportin the workplaceand at home?What approach(es)would work bestfor them?Louise Wrightexplains herdecisionmaking process
have a stammer with mixed overt and covert components butwith some natural fluency I might suggest Van Riper’s approachof initial identification, desensitisation and variation leading upto modificaton of the stammer (Van Riper, 1973). I tend tofavour Conture’s simpler version of stammering easily by mov-ing through stammers (Conture, 1990) rather then Van Riper’sdifferent types of modification. If the client is very fluent withhigh levels of anxiety about stammering and frequent avoid-ance then I would suggest Sheehan’s avoidance reduction ther-apy (Sheehan, 1975) with easy introductions to voluntary stam-mering and sliding. However, if they are stammering veryseverely our first option may be a fluency technique such asslowed speech that will give them more fluency initially and canlater be augmented with easy stammering techniques (Neilson& Andrews, 1993). Whatever path is finally embarked upon Iusually find it helpful to begin therapy with a period of identi-fication and understanding of normal speech production.
Mixture
Although I would normally outline these three main therapyoptions to the client at the end of our first exploratory session,in reality of course most clients require a mixture of these typesof therapy, either simultaneously or sequentially as their stam-mer changes and their therapy needs evolve. WASSP can againbe helpful here in monitoring progress, discussing change andplanning new phases of therapy with the client.In getting to know the person it may become apparent thatthey would also benefit from help with wider aspects of com-munication such as improved social skills, assertiveness training,anxiety management, relaxation, cognitive-behavioural coun-selling and problem solving. They may benefit from a mix ofindividual therapy, various types of group therapy and involve-ment of significant others depending upon their needs and rateof progress. Clients usually attend on a weekly or fortnightlybasis interspersed with breaks to consolidate change and takeresponsibility for their own maintenance and therapy problemsolving. Long breaks are appropriate when the client decidesthat therapy has fulfilled their needs for the present and theyalways have the option of stepping back into therapy shouldtheir needs change.My aim in all therapy is to empower the client to manage their ownstammer long-term, by helping them to acquire the understanding,therapy tools and confidence needed to react to their changingneeds and circumstances. If those around them at home and at workcan also understand their stammer and how they are dealing with it,I believe that the person who stammers is more likely to manage andmaintain change and those around them are more likely to feel com-fortable and positive about the stammer and therapy.
References
Ayre A., Wright, L. & Grogan, S. (1998) Therapy’s Long TermImpact on Attitudes Towards Stuttering in the Work-place. In:Healey, E. & Peters, H. (Eds) 2nd World Congress on fluencyDisorders, 18-22 August 1997, San Francisco, 403-406.Nigmegen University Press, Nigmegen.Andrews, G. & Cutler, J. (1974) S-24 Scale. Stuttering Therapy:The Relations Between Changes in Symptom Level andAttitudes.
 Journal of Speech and Hearing Disorders
39, 312-310.Conture, E. (1990) Stuttering (Second Edition). Prentice Hall,Englewood Cliffs, New Jersey.Craig, A., Franklin, J. & Andrews, G. (1984) A Scale to MeasureLocus of Control of Behaviour.
British Journal of Medical Psychology 
57, 173-180.Kelly, G. (1991) The Psychology of Personal Constructs.Routledge, London.Neilson, M. & Andrews, G. (1993) Intensive Fluency Training ofChronic Stutterers. In: Curlee, R. (Ed) Stuttering and relatedDisorders of Fluency. Thieme, New York.
I
 
Harper and Row, New York.Van Riper, C. (1973) The Treatment of Stuttering. Prentice Hall,Englewood Cliffs, New Jersey.Wright, L. & Ayre, A. (2000) WASSP: The Wright and AyreStuttering Self-Rating Profile. Speechmark, Bicester.
SPEECH & LANGUAGE THERAPY IN PRACTICE
SUMMER 2002
27
how I
n Swindon we have a specialist Fluency Service with fourspeech and language therapists working part-time. We seeall ages and run intensive residential courses for childrenand teenagers. I have worked in the area of stammeringfor the past 15 years. During this time ways of thinking andtypes of therapy have tended to come and go. I feel privilegedto work with adults who stammer and have met and learntfrom many fascinating and brave individuals. The uncertaintiesin the causes of stammering and its variability make it a chal-lenging area of work. I use a range of therapy approaches buthave been influenced greatly by learning more about NeuroLinguistic Programming (NLP) and brief therapy. I have not givenup my old favourites of block modification, breath control andrelaxation strategies, but tend to mix the ideas and approaches.The great thing about working in this area is that you can keepasking, “how is it going?”, “how are you finding this approach?”and gain instant feedback, something not possible in areas whereclients are unable to communicate with us so directly. The influenceof NLP is evident in my initial assessment where my priority is tobuild rapport. My aim is to understand as much as possible aboutthe meaning and the experience that stammering has for the indi-vidual, to see it through the client’s frame of reference. I aim to geta sense of how the person learns - are they mainly visual, auditory orkinaesthetic in the way they use information? This helps us select thekind of therapy activities that will create changes for the individual.In NLP the therapist is aiming to “create the conditions where-by the client may choose to change and find new and interest-ing ways to carry out these changes” (Bailey, 2001). I also takethe usual case history, gathering information about the natureof the individual’s stammering, both overt and covert features.During this process I look for clues to help understand themeaning all this has for the individual.
Pace the flow
Something I have learnt with experience is to try to pace the flowof information. At one time, following the principles of blockmodification during its phase of identification, much time wasspent analysing behaviours and covert symptoms. Whilst thisinformation is necessary, I feel that to do too much of this straightaway can be daunting for the individual, and I am sure I have lostsome clients in the past through too much analysis, too soon.Trying to get a balance between identifying the problems andlooking for solutions early on in therapy is important. It is at thispoint that the ideas of brief therapy really help. Also known assolution focused brief therapy, it looks at the client’s hopes forthe future. Rather than trying to understand and fix problems,it works by charting your way forward and seeking the resourcesneeded to embark on the journey. The essence of it is to:work with the person rather than the problem.look for resources rather than deficits.explore possible and preferred futures.explain what is already contributing to those possible futures.treat clients as the experts in all aspects of their lives.(Taken from a Brief Therapy Practice course.)Bearing this in mind, when dealing with the initial assessmentI try to take history details so as not just to get a picture of whathas gone before, but also to encourage the client to expresstheir preferred future. Looking for the client’s strengths andresources is extremely helpful right from the first session.I like to use scales as part of outcome measures. The client isasked to consider what they would like to achieve as a result of
Tippingthescales
What does astammer mean foran individual? Andwhat innerresources do theyhave which willguide therapy?Drawing on arange of approachesparticularly neurolinguisticprogramming andbrief therapyClaire McNeil asksthe questions tobring aboutchange
the work we will do together - their ‘preferred future’. Then, ona scale of 0 - 10, I ask “Where are you now?”, “How will youknow when you have moved up just one point on the scale?”,“What will you notice?”, “How have you managed to get towhere you are now?” Clients very rarely put themselves at 0, sothey are already some way up the scale. One particular clientsaid he had been feeling very depressed and could not see anythingpositive in his life. When we worked on the scale I noticed he wasable to give lots of details of how he would know when he wasmoving up. He very clearly had a step by step view of what hewould be doing as he moved towards his goal or preferredfuture. I was then able to highlight these strengths to him.Helping him to see that he was able to plan in detail and have anaccurate picture of what he wanted was a great resource for pos-itive change in therapy, and it continued successfully.
Acknowledge feelings
Using brief therapy scales helps to set goals and keep client andtherapist forward thinking. Although I do not dwell on past expe-riences, I do not ignore memories that may block future work. Itis important to acknowledge feelings. If there are issues that needaddressing, using the NLP strategies to soften the impact of thesenegative memories helps. While thinking about NLP, it is necessaryto put in a word of warning. These strategies are powerful andneed to be explored in a trusting and supportive environment.Ihave become aware of these ideas being used in a group, withoutappropriate support, and this has a very negative effect on a client.In an appropriate supportive environment I have found this way ofworking very useful in helping to neutralise past experiences andenabling clients to recognise and hold onto positive experiences.In the process of assessment I also use a general outcome scaleto have a broad view of stammering behaviours, feelings andattitudes. Avoidance schedules are also useful and it is helpfulto look back on these to gauge success. During therapy I like touse a range of strategies which vary according to an individual’sneeds. I believe it is important to explore practical ways of deal-ing with stammering at the same time as working to changefeelings and attitudes. Having practical ‘to do’ tasks in a sessioncan really help, as too much talking about things can be hard forsome clients. I very often use practical relaxation, and breathcontrol work is also helpful, enabling clients to start to take con-trol of the situation. I use block modification ideas includingvoluntary stammering which can be a real breakthrough forsome individuals. It is important not to forget some of the olderideas which can be very useful. I am now on a Charity commit-tee with someone I worked with 15 years ago; he still uses softcontacts and found this one of the most helpful strategies.It is important not to forget the need to maintain progress. Byusing techniques to manage both the covert and overt symp-toms of stammering I hope clients become aware that they havethe necessary tools to deal with the inevitable set-backs.Therapy goals do not include 100 per cent fluency, and creatinga positive attitude leads on to an acceptable level of fluencycontrol. Life events do have an impact and we need to say it isokay to have set-backs and to return for help if needed. Pastclients will sometimes call if a reminder is needed. Recently aclient I had seen in his teens came back, after 10 years, to runthrough a work presentation. After two sessions to refresh ideason managing his stammering he completed his presentation suc-cessfully and kindly rang me to let me know how it had gone.Stammering can be a chronic, ongoing disability in adults and
 
I
Prochaska, J. & Di Clemente, C. (1986) Towards a ComprehensiveModel in Change. In: Miller, W.R. & Heather, N. (Eds) TreatingAddictive Behaviours: Processes of Change. Plenum, New York.Sheehan, J. (1975) Conflict Theory and Avoidance ReductionTherapy. In: Stuttering. A Second Symposium. (Ed) Eisenson, J.

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