SPEECH & LANGUAGE THERAPY IN PRACTICE
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.
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
Stammeringtherapy is alongterm processof change that mayimpact on manyareas of astammerer’s lifeBut is your clientready to change?Do they havesufficient supportin the workplaceand at home?What approach(es)would work bestfor them?Louise Wrightexplains herdecisionmaking 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.
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.
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.