Click on the title in this index to go directly to the discussion below.
From: Scott Palasik PhD, CCC-SLP
Hello Everyone! I wanted to take a moment and welcome everyone to this wonderful online conference. I encourage you to ask questions and participate in discussions. There are many wonderful people here willing to talk with you about their experiences, research, and lives. Thank you for coming! With compassion and kindness, Scott
From: Ari (Israel)
Hello all,I want to ask how to overcome "time pressure". In my case,when I feel that the other person is on hurry ,or when i need to say just one word,or even when the other person is talking very fast.When this happen,i feel difficulty to stay in the block ,and i try to hurry my speech and my stuttering,so my speech become very tense. What advice can you give?
From: Vivian Sisskin
Hi Ari, Self-imposed time pressure is sometimes hard to resist in the moment of stuttering, but planned assignments to resist time pressure can be helpful. The instinct is that you want to slow down, and not rush, but the outcome is often better is you give yourself the message that you have "permission to stutter", and permission to take the time you need to stutter well. Assignments to resist self-imposed time pressure need not be limited to moments of stuttering. You can do assignments that put you in a position to make someone wait, and tolerate the notion that you are making someone wait. After all, think of all the times you wait for others for various reasons! Some ideas - call a store and ask "one more question" after you get the information you need or, intentionally wait a second or so before responding to someone's question (you haven't started speaking yet, so no worries that they will finish your sentence). Or, spend an extra 30 seconds or so putting your wallet away after you purchased something. Sometimes these assignments can be fun!
From: Walt Manning
Time pressure is one of the most common forms of pressure for many people and certainly for those of us who stutter when it comes to responding in a speaking situation. It is difficult to manage until - as with most things about stuttering - the speaker is able to become desensitized about the experience of stuttering in general and their own reflexive responses to the stuttering moment, in particular. Once able to "stay in the moment of stuttering" you can begin to monitor what you are doing with your vocal tract (e.g., are you achieving air flow, voicing, proper articulatory positioning, etc.). You can then begin to "play with" your forms of stuttering and produce easy, or easier stuttering rather than releying old, habitual, coping responses that enabled you to escape from the the moment. As difficult as it is at the outset, going directly at the problem and experimenting with how you are stuttering is one of the best ways to manage the experience.
From: Ari (Israel)
Vivian,I am not a patient man and I also become very tense when people waiting for me not just with my speech ,so your advices are exactly for me and not just for my speech. Walt, i am trying to stay" at the moment of stuttering" 4 years now ,I learned that I need to try not to move forward until the tension(on the next sound) is very low,but in some situations it is very hard,and i suspect that i don't let myself the time to be in the moment and i think too much fast about the next sound(because of the time pressure). Thank you all!
From: Keith Boss
Ari, Time pressure is a very interesting topic on two fronts. 1. The way our brains work. With training and practice, we can choose many, many more things in our lives, as against running on auto pilot and letting events / other people dictate our choices. With practice, we can choose to try to respond at their speed, or we can choose to respond at our speed. e.g. If we are asked a question, we can choose how soon we open our mouths to answer. We can allow pause for thought and to change our body posture to relax muscles in the upper part of our bodies. Then we answer at our speed. Practice this with relatives if you are able to do so, and slowly increase the practice to a wider circle. 2. Again, with practice, we can choose how we speak. I do not stammer/stutter when I sing, or speak in unison or speak alone. I concluded external events changed my stuttering speech state. If you take on a character when acting. This is also a changed speech state. OK I looked at other renowned speakers. I listened to politicians. They say a phrase and introduce a pause, for applause. Then they speak the next phrase. With practice I began to speak like this, at times. When doing this I had no blocks, repetitions, hesitations etc. When doing this I had changed my stuttering speech state, because I was 'taking on the role of a politician'. I enjoy speaking now. Have fun practicing. Keith
From: Ari (Israel)
Keith ,when I (and others like me) are going to stutter ,we feel we cant talk.So to prevent the stuttering moment is not an option.I learned that only when i will feel that stuttering don't prevent me to comunicate,I will stutter less. Kevin,it is nice to see you again,I know what you are talking about,today i feel the time pressure even when I am not stuttering.It make sense cause i have very good memory,and I remember so many times that people didn't listened to me and just left ,or didn't take my words seriously. Thanks all Ari
From: Kevin Eldridge
Ari, Hi... Nice to hear from you again :) I thought Vivian's advice was excellent. I used to think I felt time pressure because I was afraid I would stutter. Now that I don't stutter much, I still feel time pressure. I often feel that I am not "worthy" of someone else's time and rush when talking to them. This is a constant struggle to realize that YOU have the right to take the time you need. So... good luck!
From: Kathy Swiney
I have found a few articles including two from past years of this conference, one in Perspectives, and a few other references. Does anyone know of any other information on treating stuttering when TS is also present?
From: Judy Kuster
You may be interested in a brochure from the Stuttering Foundation put together by Luc De Nil and Paul Sandor
From: John Tetnowski
Here are a few references: Tetnowski, J.A., Richels, C., Shenker, R., Sisskin, V. & Wolk, L. (2012). When the diagnosis is dual: Stuttering and concomitant disorders. ASHA Leader, 17(2), 3-8. Van Borsel, J. & Tetnowski, J.A. (2007). Stuttering in genetic syndromes. Journal of Fluency Disorders, 32, 4, 279-296. The references in this section will also be helpful. Thanks for your interest in this area. John Tetnowski
From: Jim
From: Ken St. Louis
Hello Jim, Good question about Joe Biden. Ideally, we could just write and ask him, but I suspect with the election coming up, he would be too busy to reply at this time.
From: Lisa LaSalle
Yes, for those interested, there is a part 1-4 on you tube of Joe Biden's Gala speech about his stuttering from 2008 http://www.youtube.com/watch?v=NXxibh6wS7s
From: Judy Kuster
Joe Biden's keynote speech at the NSA convention was a remarkable speech. One thing I remember from his speech was his determination and continuous practicing in front of a mirror as well as his unconditional support, especially from his mother.
From: tim mackesey, CCC-SLP, BRSFD
Catholic nuns get significant credit for beginning his recovery. In People Magazine story immediately after The King's Speech movie Biden explained that nuns marked passages into phrases (fluency shaping). Once he integrated phrasing tempo they had him recite poetry in front of a mirror. In the People article a copy of a 2011 speech in Russia showed his phrase mark discipline he learned from the nuns. Joe gets credit for taking that cadence training and generalizing it.
From: Vivian Sisskin
I was at that talk, and one thing I remember him saying was that while he had no trouble talking in front of heads of state, he still, on occasion, had trouble ordering his coffee at Starbucks. It was a great illustration of how individualized the "fear hierarchy" is for PWS, and how variable symptoms can be for all.
From: sachin (TISA)
My question might seem "same old stuff"- but I ask it on behalf of thousands of TISA members (a self-help association in India). IS THEIR A CURE? If some people experince spontaneous recovery in their adult life, can a therapist too claim to pull off the same phenomena for an adult stutterer? Can NLP cure stuttering? Can DAF cure stammering?
From: Dale Williams
Tough question, Sachin. "Cure" would mean (to most people, I think) no more stuttering & no more thinking about stuttering. If so, here is no universal cure for stuttering. Effective therapies exist, however, so all is not lost.
From: Sachin
I have been saying exactly this to many of pws here in India. But every now and then a young pws or a young therapist is able to sow the seeds of doubt in my gullible mind! Thanks for clarifying! It is so surprising that inspite of all the evidence to contrary, many here believe that there IS a CURE, known to a few experts and that it can be bought for right fee or which can be brought about "if you believe 100% in yourself and practice technique x exactly as I tell you for exactly Y number of days"..
From: Dale Williams
Good point. It would be odd for someone to solve a disorder that has plagued people for all of recorded history, then keep it a secret to all but a select few.
From: Kevin Eldridge
So India is much like the US. There is always someone who is offering a "cure" (for many different maladies), that will work if you pay them enough money, and do everything they say exactly as they say it. Therefore, if YOU are not "cured" it is YOUR fault not theirs! We call these types of people "Snake oil salesman" and they have been selling their product for hundreds of years. ARGH!!! BUT... change is possible, so as Dale said, don't give up hope.
From: Sachin
Panacea from Himalayas Thanks Kevin! In India, we have people who descend from Himalayas and claim to have found the wonderful herb which can cure AIDS, Diabetes etc. Miracle workers! We also have a Rational Society, which keeps chasing them and blasting their myths.. But a sucker is born every minute, as they say in USA!
From: Keith Boss
Hi Sachin, A very interesting question. I recently spent 4.5 days at the Arlilia Stuttering Correction Center in Moscow. They have opened two more centers in Poland. Like many SLPs/SLTs they have been trying for decades to offer the best help possible to PWS of all ages. They have tried, refined, discarded many methods. They have now homed in on a combination of holistic treatments which remove the existing stuttering speech state and build a new speech state. Patients become 'stutter free'. I observed the process by joining groups at different stages through the up to 320 hours of work with SLPs. I can testify the 'stutter free' aspect (having seen video of them before treatment), but did not have the opportunity to ask or see what was going on in people's minds. I do know from school and parent's reports that a 'cure' (both speech and mental attitude) did take place. One child, several years later did not remember stuttering. (I cannot say if this child was one to the 20% possible persistent stutters). I want to make SLPs/SLTs world wide more aware of what they are doing. I am working with them to make this happen. We must Skype soon so I can speak more. Keith
From: Sachin
Dear Keith Being a medical doctor and a pws- I am afraid that a real breakthrough will have to be vastly different and a radically new approach. Current evidence favors a biological basis. The psychological component melts away slowly. A rapid dissolution- sometime shown in dramatic stage shows, using Hypnosis or NLP etc, is only that - a drama, a momentary high. TISA is full of people who have been led up the "garden path" so many times. This is why my approach is: Acceptance coupled with slow and steady work on COMMUNICATION skills".. If they have really hit upon something new, I will be very happy to read their paper in a forum like this.. sachin
From: Dick Mallard
Sachin, great statement--Acceptance coupled with slow and steady work on COMMUNICATION skills. I especially like the communication skills aspect. I believe you are correct. Best wishes.
From: sachin
Thank you Dick! This is based on my personal experiences, research and also based on counseling many PWS in our self help association. Literally thousands of young pws are attracted on the basis of some or other "new" gadget, technique, approach etc etc every day. It is painful really! Surprising too, because "stammerers are supposed to be very intelligent people"!
From: Vivek
Intelligence has got nothing to do with belief Sachin. In our Indian society we're led to believe many things without any back-up data or experimental proof or evidences. So, it is but natural that people of India are more vulnerable to believing such things than compared to others in the more advanced worlds. Acceptance is really good but that doesn't mean we should stop working on our communication skills which you've rightly mentioned earlier. And during the course, like yourself, if we can attain a certain level of fluency then there's nothing like it. Vivek
From: Fiona Jack
I am an SLP working in Scotland. I would like to set up group intensive work, either for a shorter, more regular period, like a Fluency Friday or a longer more intensive session for 1-2 weeks. What should I say to convince my manager that this will be required/effective, given that it will require more staffing/resources? Also, do these groups work for a wider range of children or is it best to have separate groups for 7-10, 10-14? I'd appreciate any help to get this idea off the ground.
From: Nan Ratner I have a personal belief about setting groups up to maximize the effective interaction among members with similar ages and/or profiles, so I would go for different groups. More to your point, work covered in the last edition of the Handbook on Stuttering (2008) suggests that more intense, group-format therapies have very good outcomes to report. In fact, they often exceed what can be done in reports of one-on-one therapy, and you probably have local data (evidence farming) to use as a basis to either meet or exceed on a trial run of this format. Nan
From: Fiona Jack
Many thanks Nan I also feel comfortable with grouping by age for maximum effectiveness. We have at present very little data collected on outcomes and this is something I will be looking at. I have run groups before which were well received by those that attended but one hour a week over six weeks just seemed to me like not enough to effect lasting change, though some did benefit. I would hope to extend that to 2 hours at least or have longer, less frequent meets, like three hours once a month. I there any evidence on how 'intensive' a group has to be or is the beneficial effect of it being a group sufficient?
From: Lisa LaSalle
I would add to Nan's comment that pp. 143-145 in particular in the Handbook of Stuttering (2008) summarizes some of the brain imaging studies, more applicable to outcomes of adults who stutter than younger clients at this point in time, of pre- and post-intensive treatment - "plasticity and change following treatment. Best of luck to you.
From: Gary J. Rentschler
I've done a lot of work with adult fluency groups and have seen that they are of true benefit to those who attend. I think its important to remember that speaking is a social interaction and stuttering, therefore, should be addressed in a social context. One of the unseen benefits for clients is that they find that they aren't the only ones who struggle with stuttering. They learn from one another, even when they're experiences stuttering are not exactly the same. I would tend to have separate groups based upon age, as you suggest. The differences in social involvement varies by age greatly in childhood and I think the groups would have a more cohesive core which would benefit participants. Best of luck with your venture. GJR
From: Ken Logan
I've done a fair amount of group therapy over the years - some during my days as a school-based clinician, some during my doctoral program with Ed Conture, and some while here at the University of Florida. The benefits that I've seen include the ability to help people quickly establish a basic capacity for implementing fluency management skills and, as Gary said, the opportunity to learn from others who are dealing with similar challenges. The latter is especially valuable for "generalizing" changes beyond the beyond the group. As Nan said, there have been many published studies for group/intensive therapy outcomes. I think one thing that has come out of that research is the need to plan for some type of follow-up or maintenance work after the "intensive" phase ends to minimize the risk of relapse. One final point is that I've found it's very possible to "individualize" therapy within the context of a group approach (e.g., break -out groups, "mini-lessons" and so forth can be used to address objectives that pertain to only some group members). Good luck!
From: tim mackesey, CCC-SLP, BRSFD
Realizing that anxiety and avoidance are a common concomitant issue with stuttering, CBT is a vital skill set for SLPs treating pws. Different modalities of CBT seem to come in and out of fancy within the field of SLP. Does the industry seem to have an "approved list of CBT modalities?"
From: Barbara Amster
Tim I'm not sure what you mean about an "approved list of CBT modalities" but most forms of CBT help people to explore their automatic thoughts which can lead to negative emotions, develop more rational thoughts, and set personal goals. These types of activities are good for everyone including people who stutter.
From: Ken Logan
Hi Tim, I'm not exactly sure what you mean by "modalities," but from what I've seen most of the variations in CBT are derived from the work of Albert Ellis. One source that I've found helpful for examples of CBT implementation is Egan's book The Skilled Helper. Seligman's work on "learned optimism" is based upon CBT principles as well. As you probably know, there have been several research studies on CBT application with stuttering. One recent one is by Menzies, O'Brian, Onslow, Packman, St Clare, & Block (2008) Journal of Speech, Language & Hearing Research, 51, 6, 1451-1464. In that article they reference a "cognitive restructing package" which had been set up for use with people who stutter. So, as I think you were saying in your post, there's not one "set way" to implement CBT. Still, from what I've seen, many approaches are similar with regard to main components (which Barbara outlined in her post.) Ken
From: Lynne Shields
Tim, Ken gave some good resources. Another is the publications and workshops out of the Beck Institute near Philadelphia, Pennsylvania. I attended a three-day workshop for working with teens who have anxiety disorders this past spring, and I found the information most helpful and easy to transfer to working with PWS. Judith Beck and her colleagues have written some quite readable books and workbooks on using CBT. Regards, Lynne
From: Joe Donaher
Tim, I am always a fan of learning an approach from professionals that actually use the approach. This is especially true with an approach like CBT where many interpretations exist. Obviously SLPs utilize many CBT techniques in therapy but I found it helpful to get a strong foundation in the basics of CBT prior to "playing" with it in therapy. I have learned much of what I know about CBT from Marty Franklin at the University of Pennsylvania. He has published a great deal and runs the Child/Adolescent OCD, Tics, Trichotillomania, & Anxiety Group (COTTAGe) where they offer professional training courses. A second resource here in Philadelphia is the Beck Institute for CBT (actually located in Bala Cywyd). They too offer professional trainings.
From: tim mackesey, ccc-slp
Thanks to all who replied. In pursuit of removing my own stuttering phobia of 25 years- and then helping pws thoroughly- I have spent two decades integrating CBT into stuttering treatment. I have have taken training in Interactive Guided Imagery, hypnotherapy, NLP. I have also studied multiple other modalities of CBT. I have used a package of CBT tools for my 20 years as an SLP. I see Solution Focused Therapy (SFT)seems to be an accepted modality for stuttering. The SFA has a terrific DVD with SFT for stuttering. The creator, Steve De Shazar, studied NLP with Steve Andreas- an early pioneer in NLP. Both NLP and SFT are superb when used appropriately by a skilled practitioner. The art of conversational reframing is like fly fishing; it takes finesse to present the fly and it takes precision to elicit the cognitive distortions and know what to do. The book "Mindlines" is the single best book on conversational reframing. Anxiety about stuttering is one of the major causes of relapse following therapy. As a clinician helping pws I am thrilled to see more and more CEU in CBT.
From: Ed Feuer
There is apparently no diagnostic imaging research - and perhaps other research - on covert stuttering because SLPs cannot agree on a definition. On Feb. 20, 2011, Nan Bernstein Ratner, one of the professors here, stated on the Stutt-L listserv: "There is, and I repeat this, NO ACCEPTED definition or diagnostic protocol to diagnose someone as a covert PWS." In that same thread on the same date, she also said: "I repeat, we DO need to do research on covert stuttering, and the first step is to develop a protocol that actually clearly diagnoses it to people's satisfaction." I find this situation nothing short of astounding because people are self-identifying as covert, there's been a whole lot of hurtin' goin' on and all of us overt people have been covert at times to the extent we can get away with it. But Nan is a highly credible source. I'm not an SLP nor do I play one on TV but my layperson's common sense says put some volunteer coverts in a fMRI, tell them to say some feared words for which they'd ordinarily walk a mile to substitute and see what shows up on the screen. By not doing this, you are closing off a very significant area of study. What do the other professors think of this state of affairs?
From: Gary J. Rentschler
I think you'll find that research studies start off with a theory to prove or disprove, rather than a "let's look around and see what happens" strategy. fMRIs are not inexpensive and exposing subjects to the risks inherent in the procedure doesn't seem prudent. What would you expect to see that would be different from a person who stutters overtly?
From: Ed Feuer
Why? Ultimately, because it's there, Gary. The covert people can hide stuttering better than the overt people. I'd like to know how this is manifest in what's going on in the brain. What are the differences? It should be seen as a reasonable and compelling area of inquiry for those who want to help solve the mystery of the disorder and help those afflicted. But we're told there can't be any research studies because you folks can't agree on a definition of covert stuttering. Something's wrong with that situation.
From: Nan Bernstein Ratner
I actually think there is something that bears researching here. I would expect very atypical scores on affective/cognitive measures such as the OASES or BigCAT in people who stutter covertly, in the absence of overt disfluencies. We could arrive at a definition through a modest amount of research. When I did the Handbook revision a few years back, we only found 2 articles on this topic, both very old. I actually DO think that we need to do some research with this population to understand the phenomenon better and better aid people with this profile. best regards, Nan
From: Charlie Osborne
The prospect of researching covert stuttering is an exciting one! There was an excellent discussion on covert stuttering in an article in the Division 4 Perspectives on Fluency and Fluency Disorders, August 2007 by Bill Murphy, Bob Quesal, and Hope Gulker, FYI.
From: Ken Logan
Like you, Nan and the others, I do think the process of "covert stuttering" is interesting and worth exploring. Perhaps rather than exploring it as a categorical phenomenon (Covert group v. Overt group) right away, it would be more fruitful to begin by looking across all people who stutter and identifying factors that are linked with things such as (a) the neurological events that precede impending disruption in fluency, (actually, some of this work has already been done in studies of speech motor control) (b) the ability to attend to/self-monitor various speech-related processes (some of this work has been done as well), (c) the tendency to respond to anticipated difficulties (including disfluency) with adaptive strategies such as avoidance/word substitution, and (d) as Nan suggested, profiles of communication-related feelings, attitudes, and beliefs, as well as perhaps temperament, personality, etc. I would anticipate that "covertness" exists along a continuum: some people show little tendency to conceal anticipated difficulties in fluency; many show a modest tendency to do so; and some show a strong tendency to do so (and among the latter, I would expect that the tendency to do so would vary over time and across situations). Perhaps even before all of this, it would be worthwhile to explore the process of word substitution/paraphrasing among people who do not stutter so that general principles and pathways can be identified - actually, I'd be surprised if some of the latter work has not already been conducted within the context of lexical retrieval research, for example "tip of the tongue" states). Some of the neuroimaging work with people who stutter has looked at neural activation patterns under the condition of imaged overt stuttering. Whether that's related to "covert stuttering" or not is debatable, but it's in the ballpark, I think. One final thought...I think folks have a hard enough time modeling the processes that lead to overt disfluency in stuttering - I think once that area is better understood, then folks will tackle other topics, such as "covert repairs."
From: Pamela Mertz
Jill Douglass, PhD, has written an article on covert stuttering for this ISAD conference. For her doctoral dissertation, she studied covert stuttering and uncovered the needs for much more research. You all should be sure to check out her article. It's toward the top of the article selection. I have a special interest in covert stuttering as I tried to pull it off for about 40 years. ~Pam
From: Joseph Nsubuga,Easy Speak Association,Uganda
Dear professors, I am a person who stutters and i have never almost attended a speech therapy course, I do face many people who stutter in my country and they ask me what can we do to control our temper given such unwelcoming confrontations in a society where speech therapy in almost not there? What can we teach/tell them
From: Judy Kuster
Hi Joseph! Your question is an interesting one. Actually, sometimes getting angry is a good motivator!! I believe it is what you do in response to that angry feeling that is important. I know that in Uganda there are very few, if any, options for speech therapy for most people who stutter. That is why what you are doing to raise awareness of stuttering and to develop an active network of self-help groups in your country is so important right now. One important goal of the self-help groups could be to organize an information campaign in Uganda about stuttering - what it is and how people can be helpful when they meet with another person who stutters. Another goal could be to educate teachers and all children about stuttering. An understanding of stuttering is not only important for those who stutter, but also for those who don't stutter. The Stuttering Foundation, the British Stammering Association, and the Stuttering Home Page all have good materials online that can be downloaded free to help in educating people (including teachers and children) about stuttering. I'm not sure of the language of most people in Uganda, but there are translations into 18 different languages of two of the Stuttering Foundations good informational brochures that were on a previous 10 th ISAD online conference. So, my suggestion at this time is to channel the energy that anger creates into a positive campaign to educate people in Uganda about stuttering, and maybe even getting something organized for October 22 - International Stuttering Awareness Day. Good luck and best wishes! Judy
From: Ellen-Marie Silverman
Hello, Joseph. I think that almost anyone who feels misunderstood feels some degree of anger about what seems like rejection and even more anger if we feel ridiculed for doing what we ourselves do not wish to do but do not feel able in the moment to change. And I think Prof. Kuster has provided you with some good leads for how to help yourself and give good counsel to those who ask for your advice about successfully conducting themselves when they experience bullying. >>> I would like to add to the information she provided the suggestion that you consider learning some mindfulness practices that I have found useful in just those times. Learning them helps us to respond thoughtfully rather than simply react with angry outburst or silent withdrawal to the pain and hurt such thoughtless words and actions can trigger in us. Learning then applying these strategies can take time, but they are well established after a history of more than 2,600 years of practice! At the risk of seeming to make a shameful plug, I would like you to know that a book I have written, "Mindfulness & Stuttering. Using Eastern Strategies to Speak with Greater Ease" may be available at the end of this year or the beginning of next year. It contains much information about dealing skillfully with bullying that you may find helpful. Best wishes, Ellen-Marie Silverman
From: Vivek
Hi Joseph, I guess this article on stuttering brain will give you a little insight about mindfulness in stuttering - http://thestutteringbrain.blogspot.in/2011/06/mindfulness-in-stuttering.html ~Best,Vivek
From: Ed Feuer
Being a kid who stutters and a member of a minority group in school is a particularly bad combination and a double whammy as regards bullying and ostracization. Has any specific and recent research been done concerning this issue? � Ed Feuer edfeuer@mts.net
From: Judy Kuster
Open scholar.google.com and type in Gordon Blood bullying He is scheduled to do a 2-hour workshop on the topic at the ASHA convention in November.
From: Ari (Israel)
I want to ask why almost all the therapists that treat stuttering are afraid of touching the stuttering itself and they just focused on fluency? Even when they work on fear ,they work only on "fear to talk fluently" and not on the fear to show the stuttering/on the fear to stutter.
From: Ken St. Louis
Hello Ari, Good question, but I believe a bit over-generalized. I respect your experience, and it must be the case that most or all of your clinicians have not wished to focus on fears. That's too bad, in my opinion, since that I believe that desensitization is a very important part of providing best practice to people who stutter. Many current clinicians are not at all reluctant to deal with the fear of stuttering. I will hasten to mention, however, that some others disagree and believe that those of us who deal with emotions related to stuttering are "throwing in the towel." That aside, let me get to your question of "why" clinicians are reluctant to deal with emotions. The answer is no doubt complex. I wrote a paper many years ago on a related topic, i.e., why clinicians are reluctant to treat stuttering at all. Here are some of my thoughts: First, I suspect that clinicians are reluctant to address fears because they have not been in practicums or actual clinical situations where that has been done. In other words, they simply don't feel comfortable doing so because they have not done it before. Or they may have had no training in desensitization and simply don't know HOW to do it. Second, it is likely the case that some clinicians believe that dealing with emotions is the job of the psychologist or psychiatrist rather than the speech-language therapist/pathologist. Third, it seems to be a logical deduction that if one could eliminate the stuttering, then the attendant emotions will simply diminish and go away. That does sometimes happen, especially in stutterers with mild stuttering, with stutterers who are especially resilient, and with very young stutterers. In my experience, however, it usually does not happen with people who have stuttered for many years and therefore have come to view themselves as deficient speakers. I try to drill into my students the following: "ROLE CONCEPTS CHANGE SLOWER THAN BEHAVIOR." So even though a person might become fluent in individual therapy, he/she typically still has the self concept or role concept of a person who stutters. It may take years or even decades for that to change even if the person does not revert back to stuttering. I've probably rambled enough. I hope this addresses your questions. Good luck and stutter well! Ken
From: Ari (Israel)
Thanks Ken for your informative answer. You wrote"So even though a person might become fluent in individual therapy, he/she typically still has the self concept or role concept of a person who stutters". The problem is that most stutterers wont be fluent even after they passed the most successful therapy they could passed. So when the therapists don't touch the "Hot stove"(stuttering) the patient need to decide by himself what to do when he feel the stuttering again. Almost all the therapies teach the client how to be fluent but not what to do when the stuttering appear again.
From: Ken St. Louis
Hi Ari, Thanks. I just finished a lecture the other day on transfer and maintenance. I told my students that by never mentioning relapse, they are creating the impression that relapse would be failure. I don't recommend clinicians tell their stuttering clients that relapse is inevitable, but I do recommend that they tell them that relapse is very common. Moreover, I suggest that they communicate in whatever way seems best that relapsing is not failing but just part of their client's journey. Some people relapse one or two times; others relapse many times. A few don't seem to relapse much at all. Each person's stuttering and the context within which it occurs is sufficiently unique that no one can predict for sure who will relapse and who will not. It's best therefore to prepare the person psychologically for a relapse so that if it happens, he/she is not so devastated and self-defeated. For most adults who stuttering if I can arrange it, I ask my students to help them make a one-week plan to follow if a relapse occurs. The main principle is, "Don't dwell on the relapse and worry about it. Just DO what you wrote down!" The plan has all the major pieces of therapy, going back to every major step (even the most exaggerated ones) in mini-form. It seems to be well accepted by clients who have seriously come through a hard recovery process. Ken
From: Ari (Israel)
Ken, sorry for digging ....(like we call it in Hebrew). Something I don't get it is: what you call relapse? I call relapse to a client that came to a place that he can deal with most speaking situations, and that know how to deal with stuttering, without avoiding words or situations, and suddenly he feel that he lost his confidence and the fear and avoidance is coming back. I think that to really come to this place you need in most cases to work on your speak for quite long period. The most treatments don't stand up for such long time, and the client finish the treatment without really overcome his fears, so i don't call it relapse i call it, waking up from the illusion of fluency. So what is relapse for your opinion? Thanks!
From: Ken St. Louis
Hi Ari, I guess I would regard both of your examples as relapse. In one case there is a relapse after a fairly long period of improved fluency, confidence, freedom from fear, etc. In the other case, the relapse occurs quickly. Perkins used to call what you term the "illusion of fluency" with "lucky fluency," which he said is rarely permanent. I have seen a few cases who have improved immediately and never gone back to stuttering much at all. Ken
From: Ari (Israel)
The SLP'S that treated me wanted to work on Fluency or to convince me that stuttering is OK. None of them asked me to stutter with them in order to hear how I stutter. None of them tried to reduce the severity of my stuttering. The choices i had was to accept my stuttering, that mean very hard silent blocks with a lot of tension, or to speak fluently. Neither of them were suitable for me. The first time I understood that it is possible to stutter with less tension ,was when I saw Peter Ramig demonstrate it on SFA movie.(I don't think that in USA the situation is a lot better) Thanks!
From: Scott Palasik
Ari, HI! Could tell me a little about your experiences with treatment, in some more detail? There are many therapists out there who do much MUCH more than just focusing on Fluency. You will find many of them here at this conference. Feel free to ask any of us what styles we practice with respect to counseling clients through the cognitive behaviors (thoughts and perceptions) related to stuttering. Thanks for your question and interest in this field. Scott
From: Ari (Israel)
Scott ,i know that the therapists on this conference are different, but it is very rare to meet such good therapists in the real world! I personally succeed to hear about ISAD and i also read a lot of books and DVD'S about stuttering, but the most stutterers don't know that it's possible to change the stuttering even if you continue to stutter. I participated in a close facebook group of stutterers from Israel, and they just talk about fluency or about living the life without pay attention to stuttering, when I mention the possible to change the stuttering, they don't understood what I want. Never the less, In a lecture from a nice SLP about treatments for stuttering, she mentioned all the therapies that she know even Art Therapy and Music Therapy, Stuttering Modification wasn't mention. Also An SLP asked me to lecture in her class about stuttering modification, cause for her opinion, it is different than the "popular therapies", and she thought that I can teach her what it is. Thanks Ari
From: Scott Palasik
Ari, First let me say thank you for being an advocate for yourself and the field. In order to grow, we need brave people on the front line willing to ask questions and get different answers. That being said, just because we have answers, doesn't mean the answers are right. They just mean we found some new information. Being able to keep asking new questions is the true sign of an individual evolving. You are asking some wonderful questions and then putting those answers into action. Nice job! Let me know how things go in the future (spalasik@uakron.edu). Have a great day, Scott
From: Kyle Tiberi
How often do you see kids who stutter get bullied by other kids? What do you recommend to teachers, parents, and the child? Are there any resources that you provide/recommend to use?
From: Judy Kuster
Open the Stuttering Home Page (http://www.mnsu.edu/comdis/kuster/stutter.html and enter teasing OR bullying in the search box. You'll find several items including good papers from past ISAD online conferences on the topic. Be sure to read the article on THIS conference Practical solutions for dealing with bullying in children who stutter by J. Scott Yaruss (Pennsylvania, USA), William Murphy (Indiana, USA), Robert Quesal (Illinois, USA), and Nina Reeves (Texas, USA). Also there are materials from both the NSA and Stuttering Foundation that address this topic. A SIG 4 invited presentation by Gordon Blood who has researched and written on this topic will be at the ASHA convention in November. Just a few suggestions to explore.
From: Karla Borsdorf
Hello, I am currently a graduate student in speech pathology, and I have an adolescent fluency client who also has Down Syndrome. I have found a few research articles about treating stuttering in this population, but they vary in their recommendations about the types of treatments to use and how to implement therapy. Does anyone have any resource recommendations, therapy techniques or approaches to use, or fun ways to implement these therapy techniques?
From: Judy Kuster
Check Kuster, J. M. (2011, November 22). Internet: Working With Children With Down Syndrome. The ASHA Leader. It is freely-available on the ASHA website and has a section of some materials related to stuttering and Down Syndrome. Also, open scholar.google.com and enter the key words stuttter +"Down syndrome" and open http://www.mnsu.edu/comdis/kuster/teaching/convention/conventionhandouts.html on the Stuttering Home Page and check handouts from the 2008, 2010 and 2011 ASHA conventions where there are 3 handouts relating to stuttering and Down syndrome.
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From: Andrew (11 years old)
If your friend stutters, and if you want to be like your friend, can you make yourself stutter?
From: Lisa LaSalle
hi Andrew, Your question is a good one. It reminds me of something that happened to me a number of years ago. I had a former graduate student in Wisconsin graduate and go on to work in the school systems, I believe it was in Milwaukee. She emailed me about a year later, that she had a case of a girl about your age, 11 whom she determined was a "malingerer." She began by letting me know that this girl was the best friend of another girl who actually stutters, who she was seeing 2x per week for speech therapy in that school. So "malingering" is a fancy word for someone who is faking the problem. But it wasn't such a serious offense as it sounds, as the girl simply wanted to go to speech therapy just like her friend who stuttered. This speech therapist in Milwaukee learned that the girl was malingering because she stuttered on every word of the Pledge of Allegiance, upon testing her. And that is quite unusual for people who stutter to stutter on every word and to stutter on something that's pretty well memorized especially when they were practicing it in chorus. She simply told the girl that there's a lot of fun things that happen in speech therapy and she could instead be a "speech buddy" to her friend who stutters. She said something like, "you don't have to make yourself stutter in order to come to visit my speech room." I have since liked telling this story in my graduate classes because it's the only case of malingering I have ever come across. I also teased the speech therapist, or SLP, for having such a cool speech room, that she may need to watch for more cases of malingering.
From: Andrew (11 years old)
If you are nervous, can you make yourself stutter?
From: tim mackesey, CCC-SLP, BRSFD
Andrew, I admire your courage in posting this question at age 11 ! Bravo. Last time you were nervous about stuttering what were you thinking about? What did you think would happen? Most kids I help do something called "mindreading"- that means presuming what people will think if you stutter. I stuttered severely for 25 years. I used to worry about people's opinion of my speech. Be brave Andrew. I bet you have many important things to say.
From: Andrew (11 years old)
If you can be happy, can you still stutter?
From: David Shapiro
Hi Andrew, I really appreciate your excellent questions. I'll address them here in one place. Being a friend is so important. In fact, some people say that "It takes a friend to be a friend" and that both being a friend and having a friend are among the best things in life. You sound like you are a good friend; I bet you have good friends too. One of the best things about friendship is that we accept our friend just as he is, and in friendship we feel accepted just as we are. So while it is tempting to stutter if we want to be like our friend who stutters, it may be even better to show our friend that we accept him and like him just the way he is. And yes, being nervous can make us stutter even more sometimes. I know many people who stutter; I am a person who stutters too. I find that sometimes we stutter when we are happy; sometimes we stutter when we are sad. But we know that stuttering is only part of who we are. There are so many other things about us that our friends really like. For example, I like hiking, camping, swimming, bike riding, and fly fishing. Most of the times my friends are more interested in those activities and don't even notice that I stutter. Let me tell you about my best friend. She's a girl and I've known her a long time. I used to stutter really badly. I couldn't say her name. I couldn't even say my own name. Actually, I couldn't say very much. Even though I sometimes still think about how bad my stuttering used to be, she tells me, "It wasn't that bad." She never saw it as big of a problem as I did. I think that is the best part of having a really good friend. My friend liked me just the way I was. She liked what I liked and she didn't want me to be any different. And I really like her just the way she is. That she is my friend makes me very happy. So I hope you too will be happy to be a friend and to have a friend. That;s what really matters. I bet you already know that. Thank you again for your really good questions. Your friend, David
From: Lynne Shields
Hi Andrew, you have asked some really great questions. One other point I would like to add here is that you might like to learn more about stuttering. That is one good way to be a supportive friend. You can ask your friend who stutters to tell you about his or her stuttering. There is also some very good information about stuttering on the Stuttering Homepage which can be accessed at this link: http://www.mnsu.edu/comdis/kuster/stutter.html Click on the links for "Just for Kids" or "Just for Teens" to learn more about stuttering. Thanks for posting your questions. Lynne
From: Andrew (11 years old)
Thank you for your support to answer these questions. I never had a friend in my life. I hope someday I will make some new friends. From, Andrew.
From: David Shapiro
Hi Andrew, I was so pleased to see your replies to all of the people who responded to your excellent questions. Also, I wanted to share with you that sometimes we have more friends than we might realize. People get busy and don't always remember to tell others what they think, particularly when they like something about someone else. We assume that the other person already knows, but often he or she doesn't. I bet you tell people what you like about them; that is a good way to make others feel comfortable and to let them know that we like them just the way they are. This is also a good way to begin a friendship. Good luck and thanks for writing back to me. David
From: Tim
How is stuttering perceived in different cultures around the world?? Is the differences in gender only due to nature.....and not the environment.....because more females do recover than boys, why? .thank you so much. How accurate is 1% or is the 1% based on limited and restricted sample size? Tim
From: Ken St. Louis
Hello Tim, You ask some good questions. Let me respond to the first one in this post. You asked, "How is stuttering perceived in different cultures around the world?" With a large number of colleagues or "partners" around the world, I have led the International Project on Attitudes Toward Human Attributes, an initiative designed primarily so far to explore public attitudes toward stuttering worldwide. I developed the Public Opinion Survey of Human Attributes-Stuttering (POSHA-S) and have published studies on reliability, validity, translatability, user-friendliness, online vs paper-and-pencil sampling, convenience vs probability sampling, etc. There is no way I can answer simply because each of the more than 150 different samples we have analyzed so far is different. Nevertheless, let me try to offer a few summary statements of what I have learned so far. (1) Public attitudes toward stuttering appear to be overall more similar than different around the world. (2) That said, there are important differences in different samples, such as those from the West (North America & Western Europe) vs. those from other regions (e.g., Cameroon, Nepal, India, China, Syria, Kuwait, and Turkey). (3) Although too soon to say for sure, a number of predictors are emerging. It appears that educational level of respondents is a fairly consistent predictor of positive (accurate, sensitive) attitudes. So, too are occupational status and relative income, but not as strong. Knowledge of stuttering from personal experience as a stutterer or a parent of a stuttering child results in the best attitudes on average that we have seen to date. Future speech-language pathologists (i.e., SLP students) have better attitudes than those inherent in other college students. Also, as SLP students move from undergraduate to graduate status, their attitudes improve, possibly even before adding further coursework. Coursework in fluency disorders can, but may not always, improve students' attitudes. Focused information on stuttering (talks about stuttering, DVDs about stuttering, stories of people who stutter) also can improve attitudes in high school and adult respondents at least temporarily. (4) The sex of adult respondents has very little effect on stuttering attitudes. The sex of the hypothetical stutterer may have some effect on attitudes, at least in some cultures. I am currently exploring this further. (5) In one carefully controlled study in Turkey using representative samples, attitudes of 6th grade children were virtually the same as the attitudes of their parents, grandparents, and adult neighbors. (6) The language of the questionnaire, if properly translated and then back-translated to English appears to make no difference in the responses. Those are some of our findings. If you want to see more, you can visit my website at www.stutteringattitudes.com. Best, Ken
From: Nan Bernstein Ratner
I'll concentrate on the prevalence question, since Ken did such a nice job with attitudes. There appear to be only minor variations in the incidence/prevalence of stuttering and gender bias; there are numerous comparative tables in the Handbook on Stuttering. The little "wobble" that appears is likely due to: genetics (some cultures, such as Cameroon, appear to have slightly more stuttering because of inter-marriage and large families); efforts and definitions in trying to actually identify the incidence of stuttering. At this point, we don't believe that culture determines the frequency of stuttering, or likelihood of recovery in girls and boys. However, living with stuttering is likely to be different in different cultures, as Ken notes. best regards, Nan
From: Klaas Bakker, Springfield Missouri
There is not much left for me to add, except for highlighting that there are different ways in which we can think about "prevalence". Prevalene, strictly points to a binary stutterer-not-stutterer distinction and doesn't particularly look at the many ways in which we stutter, react to stuttering or confront reactions to our stuttering by others. I really think the 1% prevalence number doesn't budge much across cultures, languages, and now also for a significant period of time. Even so, what happens to us if we belong to the 1% can be markedly different. Prevalence doesn't tell us anything about severity, or patterns of behaviors, and how any of these could be affected by our background and culture within or across the countries of the world. In that sense it tells us very little.
From: Ken St. Louis
Tim, Nan, and Klaas, I agree completely with what Nan and Klaas wrote about prevalence. It would seem to me that prevalence data tells us more about the risk factors for stuttering in the first place but not much about the experience of stuttering. I'm working on a project right now that hopefully will help us make some generalizations about one's individual experience of stuttering and how it might be affected by one's family-held attitudes and broader cultural attitudes. Wish me luck.
Generalized Anxiety and Stuttering?
From: Mike Lefko
I was diagnosed with generalized anxiety about 20 years ago and have been a PWS all my life. It has only been recently that I suspected a connection between the two, yet I have neither heard nor seen any research in this area. Perhaps I am just looking in the wrong places. I can't imagine no one has made the connections. I am at a point in my life where I no longer fear speaking and no longer fear stuttering. I owe that to my work with a very special therapist and professor in Western North Carolina. However, I still do stutter. It doesn't seem to be brought on by fear of speaking or fear of stuttering as it did in my younger years. Yet, I will be speaking good and strong one day, for weeks, even months, and then as was the case a few weeks ago, for no conscious reason, I began to experience more challenges, and difficulty maintaining the fluency. I don't want to say it ever controls me any more, but lately I haven't felt in complete control. There are none of the habits of my youth, such as having premonitions of failure, and fearing to speak. I have, however, been working very hard at work, and have had a lot on my mind. Now the stuttering feels more like the anxiety itself. It comes on, and I can't identify the exact cause, and can not necessarily immediately get back " on the wagon" so to speak, with my controls, and do what I know how to do. It feels like an anxiety attack of stuttering of sorts. I know it will pass. I know I have confidence I can and will speak fluently again. My "controls" aren't readily accessible. It's almost as if the train is out of control and has run the tracks. Has anyone done, or heard of specific research in the area of generalized anxiety and stuttering? I've got to think, at least for me, there is a connection.
From: Ari(Israel)
I am not one of the panel just a stutterer, but I can say that when i tried to speak fluently by Fluency Shaping, I felt a lot of anxiety including difficulties to breath .When I started to show my stuttering ,i still felt fear (sometimes a lot) but the anxiety feeling was gone.
From: David Shapiro
Hi Mike, You're asking an excellent question. My friend, Mark Irwin, has put a lot of thought into this question and has addressed the implications of - and distinctions between - social anxiety and stuttering. He has written several papers (e.g., http://www.mnsu.edu/comdis/isad11/papers/irwin11.html and constructed a website in which he lists numerous others for the public and for the professional community. His website is http://stutteredspeechsyndrome.com/ and he welcomes email contact and interaction (his email is included on his website). I feel sure you would enjoy interacting with him. Kindly, David
From: tim mackesey, CCC-SLP, BRSFD
Anxiety/fear/avoidance are a huge part of stuttering. Correct me if I am wrong, I thought most researchers in stuttering are concluding pws have "state anxiety" rather than generalized. That means pws have anxiety activated by the fear of stuttering (rather than a 24/7 anxiety problem).
From: Walt Manning
Anxiety, particularly social anxiety and fear of negative evaluation is a natural result of the experience of stuttering. It would be abnormal NOT to experience anxiety in social situations if you are a person who stutters. Of course some PWS also have anxiety disorders and other Axis I or II psychological problems but at a rate that is not different than the community population (in spite of some efforts to argue otherwise). The student in my classes who are asked to play the role of a PWS experience much the same anxiety. As Guitar (2006, p. 62) states "the experience of stuttering generates emotions, such as frustration, fear and anger in everyone who stutters." Anxiety as a result of another condition is not considered to be a psychological disorder. In fact, as noted in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) stuttering is an example of just such a condition (Anxiety Disorder not otherwise specified p. 484.)
From: Ari (Israel)
Dr Walt, thanks for your clear words!! I am trying to explain to SLP'S that the Anxiety we see in stutters is different than normal anxiety, and that to give stutters a drugs for anxiety need to be the last solution. Almost all the therapists, told me that "Anxiety is Anxiety the reasons don't mind". Thanks again Ari!
From: Jennifer
Hi, I was wondering what is the accepted theoretical explanation on why the Lidcombe program works for young children? Because its a behavioral conditioning therapy program done by parents. Its not traditional speech therapy by an SLP practicing fluency techniques. How successful is the Lidcombe methods when applied to older kids, and can the punishment and rewards basis be applied to school age children? Thanks, Jennifer
From: Nan Bernstein Ratner
There are reports of successful use of Lidcombe in school-aged children - go to PubMed, and you can find them. Most accounts of HOW it works are offered by outside researchers, myself included: manipulation of linguistic demand during home sessions, acknowledgement of the child's problem and joint work (lots of parent programs do very well), self-efficacy, there are lots of potential reasons. Rosemarie Hayhow has written on this, as have I.
From: Ken Logan
Great questions. I agree with the things Nan mentioned and, to her list of explanatory factors, I might add "enhanced or focused attention/awareness." That is, it seems reasonable to think that the highlighting of stuttering-relevant behaviors like disfluency in a program like Lidcombe (i.e., "that was smooth/bumpy") enhances the speaker's attention to/awareness of certain key facets of speech production. It's hard to change something if one is inattentive to it or unaware of it. I'm speculating here, of course, but it's probably not the focused attention, per se, that facilitates fluency, but more that focused attention leads to other changes or modifications that do facilitate speech production. It is interesting to note that many fluency therapy approaches (for example, Lidcombe, "time out," the "identification" phase of traditional stuttering modification therapy) all have a feedback or behavioral labeling component to them. One final point, it is also interesting to note that focused attention seems to have a helpful effect on movement performance in many other disorders, particularly those that stem from problems in the basal ganglia.
From: Klaas Bakker, Springfield Missouri
In my opinion a working ingredient of the Lidcombe program is the fact that it is typically used at a step in the development of stuttering when there are very few other symptoms going on. So the awareness and highlighting can be more effective as it is not likely affected by fears, negative attitudes, memories of recent negative experiences and more. I would think for this same reason other approaches would also work.
From: Tom Weidig
Hi Nan. Thanks for letting me point out the reasons that could offend someone! ;-) Here are a few more reasons: statistical error due to low sample size, no long-term follow-up which would show relapses clearly, no-shows are not declared relapses, conditioning to recording environment, only those who would have recovered anyway got more fluent more quickly in therapeutic environment, serious conflict of interest due to studies done by those who invented, use, and spread Lidcombe in terms of money, research grants and prestige, no control group, and so on...
From: Richard Mallard
Jennifer, you ask a good question. Let me suggest to you that speech therapy programs do not "work." There is nothing we can do in speech-language pathology that can effect change in a client independent of the client putting into practice what is taught. For example, the "therapy" that a dentist does "works" because the dentist does the work and the patient is passive. The same can be said of other professions as well. This is not the case in speech-language pathology. We cannot fix anything; we can only instruct. You would be wise to always view with suspicion behavioral programs that others claim "work."
From: tim mackesey, CCC-SLP, BRSFD
Dr. Mallard, I see your reply as productive. I would like to take the liberty of expanding on it. One presupposition is that an SLP trained in a program (aka Lidcombe)is that the SLP has abundant experience with the program and with pre-k kids who stutter. An SLP can take a training and have no legitimate experience with kids who stutter. If I were looking for an SLP to treat kids who stutter, I'd be keenly interested in their experience and testimonials; more than a program certificate. In a family administered program, it is a triad: family, pws, SLP. The ability to nurture parents is sine qua non.
From: Dick Mallard
Tim, I agree with your comment and appreciate you taking the time to respond. Working with the communication environment of children who stutter is, in my opinion, the most efficient way to go. Let me make one observation on what you said. You mentioned "nurturing" parents. I prefer to look at my role as "teaching" parents about stuttering and how to respond appropriately when the child comes to them with issues in the normal course of daily interaction. We can have an experienced clinician and willing parents but if the child does not put into effect what is taught then overt speech change will not take place. Best wishes to you.
From: Tom Weidig
>> what is the accepted theoretical explanation on why the Lidcombe program works for young children? The simple answer is there is no clear evidence that it actually works despite the public perception. For it to be effective, you would need to have a large sample of 100 kids at the very least, to have a long term recovery rate much higher than natural recovery, no relapses, those recovering recovering earlier, exclude the possibility of short term adaptation in the clinical/parental environment during exercises and recordings, and a control group. None of these criteria have been fulfilled. If you want to see a better quality of study, check out Marie-Christine Franken's study where she compares Lidcombe to demands and capacity. So far they see no difference as in the pilot study.
From: Lisa LaSalle
Lidcombe approach for treating preschoolers who stutter is based on a Response Contingent Stimulation model, where it involves a 5 : 1 praise of "smooth" speech : 1 correction or request for self-correction of "bumpy" speech (e.g., Onslow, Packman & Harrison, 2003). The parent-administration of this 5:1 rule becomes problematic I have found, with some parents, in some cases. Also, should Lidcombe be used exclusively in clinical cases? (whereas, obviously for purposes of research and treatment fidelity it does need to be administered by the manual and exclusive to other types of treatment). That is another question worth posing about Lidcombe. Jennifer and others interested may want to check out http://stuttertalk.com/?powerpress_pinw=1525-podcast for example.
From: Kevin Eldridge
Jennifer, You asked a great question I will give you my short answer that no one else touched on yet. I believe one of the reasons the Lidcombe program works is because the child is not told WHAT to do to say the word smoothly. Each child figures out what they can do to move forward. It helps the child to develop a skill he has, it doesn't teach him a new one.
From: Tim Mackesey, CCC-SLP, BRSFD
Kevin is right with most kids. However, some pre-k children have such tonic and severe blocking that they need to be assisted to say words. An example would be a 3 yo who has severe blocks on common starting words such as I, what, can. If SLP says at the end of severe utterance "that was bumpy let's say that again" the child may go right back into tonic stutter. That is a very precarious position. Back up and teach fluent onset. An ounce of prevention is worth a pound of cure. I just did an eval on 5 yo who stuttered on 28 items on GFTA (one word utterance). That child, and others I see, need to learn some easy onset to initiate speech. I use a multi-sensory approach with visual, auditory, and tactile input.
From: Kevin Eldridge
Since we are talking about a hypothetical 3 or 5 year old, I will hypothesize that this little guy is not blocking on every word he is saying. Therefore, before I would even think of trying to teach this pre-k child to use an easy onset, I would work with the parents to help them discover situations where the child produces more (if not all) naturally flowing speech. I would then encourage them to engage the child in natural loving communication in these settings, so that the child (and parents) experience more of this naturally flowing speech. In my mind, trying to ask a child that young to speak in a volitional way is much more precarious.
From: Reuben Schuff
From your decades of experience in clinical practice working with people who stutter, have you observed any common factors in your adult clients who have been successful in overcoming their stuttering disorder and maintaining lasting positive change in their lives and communication skills?
From: Lynne Shields
Hello Reuben, There are quite a few factors that contribute to successful management of stuttering for adults. A few that I have seen as important among the people I've worked with are: 1) being ready for change (as opposed to just wanting change to happen), 2) having fairly specific goals (as opposed to wanting the stuttering to go away), 3) developing tolerance of stuttering, allowing them to experiment with their speech, 4) readiness to manage negative feelings and attitudes about their stuttering, if appropriate, and 5) the willingness to experiment, facilitating problem solving and independent management of their stuttering. There are certainly others, and I am sure others will share their viewpoints, as well. Best regards, Lynne
From: Ellen-Marie Silverman
Hello, Reuben. The sequencing of the two words "lasting" and "change" in your question grabbed my attention this morning. I recognized them as communicating that it is in our hoping that when we get what we want and that when we achieve what we wish that we will have what we want and do what we wish as long as that is what we want. And, from my perspective, it the kind of thinking that make us frustrated. /// We know everything changes, and we know that when we substitute new ways of thinking and new ways of behaving for ways of thinking and behaving we no longer want to continue that there will be times we will "rubber-band" back to those now unwelcome ways we formerly thought and acted. This is what we label "relapse." /// If we think of relapse as an inevitable aspect of change, which it is, rather than reacting to it as a sign of failure, and if we respond to relapse as a reminder, no more and no less than that, to keep on keeping on using the practices we already have been using to speak more as we wish, we set the state for effectively managing inevitable relapse, which may occur from time-to-time. Let's just consider relapse as feedback, a reminder to keep at it. /// Hope this refreshes your view about relapse. Ellen-Marie Silverman
From: Reuben Schuff
Ellen Thank you for your response. I think I see what you mean about my phrasing. Change is never static. One of my favorite quotes is "when growth stops decay begins" I think you have insight about incorporating relapse, as you describe it, in to the process of change rather than viewing it as a failure. While I'm no wordsmith or therapist, the connotation of term "relapse" does seem to have a negative aspect. What you're describing, I would simply call a habit failure. Perhaps this would have a similar negative connotation to someone else. Whichever term we want to use, I feel it's been an important part of my journey to learn to recognize these habit failures and continue working undiscouraged, knowing that I'm on the right track for the long road.
From: Ellen-Marie Silverman
You seem to have found a path you can travel, Reuben, with self-awareness and self-confidence as companions. Wonderful! Best, Ellen-Marie
From: Scott Palasik
Reuban, HI! Great to meet you (virtually) and from what I've read you are on a great path. It's funny, for many years (being a person who stutters and a professional) I spent time focusing on the stuttering I was doing wrong or my speech errors (perhaps termed as failures). However by just focusing on them I wasn't going anywhere with them and instead I was 'judging' my speech repeatedly. So lately I've been taking notice of all my speech, trying not to judge it. Just being WITH my speech (without judgments) has opened up doors of perceptions allowing my speech to evolve. Not looking at changing the failures, instead observing my behaviors of delivery, if I said what I wanted to say, and if the words Ii chose represent me at the core; my values as a person. Noticing if the message I truly wanted to convey was what I actually said; content. Evolution of a person can be an important part of a valued-based living existence. Good luck on your journey! With compassion and kindness, Scott
From: Ken St. Louis
Reuben, Great answers already to your question. Here is my favorite quote when it comes to who is most likely to succeed as an adult who has stuttered for years: "Stutterers who are successful in transferring and maintaining fluency have made conscious decisions to assume responsibility for their own maintenance, have confidence in their therapy skills, and have sufficient control over cognitive attitudinal and feeling variables to modify their speech when necessary" (Richard Boehmler, 1981) Ken
From: Retz
Rueben - You ask a great question! Just my view...... As a 58 year old person who stutters, and as a professional who has worked adults who stutter & getting to know many adults who stutter through various self help groups over the last 31 years - my experience has been that the single most common factor in "successfully" overcoming the stuttering disorder and maintaining lasting positive change in their lives and communication skills is IDGAS; As well, true IDGAS in a PWS is perhaps the most difficult part to obtain in the recovery of natural speech by a person who stutters. Great Question!
From: Vivian Sisskin
Reuben, You have received some very thoughtful responses, and I will add mine as well. I think those who achieve lasting change have gradually (1) ceased to engage in behaviors that are intended to hide one's identify as a PWS (2)ceased to view stuttering as something to manage or control. Vivian
From: Kevin Eldridge
Reuben, I thought I'd add one or two more points. I have found that those that are "successful" in therapy are able to look at the gains they are making (even if they are small) as positive movement toward their goal, as opposed to focusing on how much further they need to get. These folks also are able to see themselves as the agents of their own change.
From: Vivek
This is an interesting question which i wanted to ask here. Its not related to any research though but its certainly a very relevant question for some of the stutterers visiting here: How do you react/respond to a person who keeps cutting you whenever you speak up. And how do you not let people victimize you especially somebody who doesn't like you. ~Vivek
From: Lynne Shields
Dear Vivek, This is a good question and I know it is a real concern for many people who stutter. There are many responses that can be made to speaking partners who interrupt you or who are rude or unkind to you because of stuttering. The way you might respond to those type of situations will vary based on your own personality and communication style, as well as the specifics of a particular incident. The important issue, from my point of view as a speech therapist, is for a person who stutters to find ways to respond that allow them to be true to themselves and to act on the knowledge that they have a right to be heard, and that no one has the right to try to make them feel badly because they happen to stutter sometimes when speaking. Responses can vary from being very straightforward ("I'm not finished talking yet", "please do not interrupt me", "I don't appreciate your rudeness"), to joking (for example, if they mimic your stuttering, "I can stutter better than that; would you like me to show you how to do it?"), to simply ignoring someone who is rude or walking away from them. I think it is important to choose responses that allow you to assert your right to speak and to be treated well, but that fit your own personality and style. I wish you the best! Regards, Lynnec
From: Vivek
Thanks for the reply Lynne! There are few very good points which you've mentioned. I'll keep that in mind when i face such situations in the future. Could you please tell me how should i respond to somebody who doesn't like me for instance, he has a personal grudge and he sees my stutter as my weak link so he tries to exploit that and make me look bad in front of others. How do i respond to such people who's intention is just to hurt me. I may/may not know the person's intentions, so how should i deal with such people. Please let me know if you have any difficulty in understanding what i'm trying to ask. I'll be really happy to clarify it further for you. Thanks a ton again for your help with this. ~Regards, Vivek
From: Scott Palasik
Vivek, Good day! You ask great questions. The important part (well one of MANY) is how a person relates their cognitive behaviors to their external actions. Lynne said it well, you can react to people in a manner that is true to you as person. This goes for all our reactions, the only thing we have some control over is our reactions. Speaking of control, you asked how you can respond to a person you "think" doesn't like you because of your stuttering. I have had this thought many times in life (being a PWS and a Professor). Something that really has helped is to come back to things I can control. Can you control other people's thoughts? Can you control how people react to you? No is the reality. Then, from there you can just be you. Be yourself at the core, your honest self. If this person still doesn't like you for you, that is their choice. Will you stop talking because someone else chooses to have the thoughts they have? Hopefully not. At the end of the day we can answer to one person, ourselves. We can do things that fit our values at the core, and let others choose their own paths. Sometimes we meet people who share our values, and thoughts, sometimes we don't. Such is the wondrous beauty of each person being different. Great question Vivek! Have a great day! With compassion and kindness, Scott
From: Vivek
Thanks for a wonderful reply Scott! I really appreciate it!! ~Regards, Vivek
From: Lynne Shields
Vivek, I really like Scott's response to you on your second post. Focusing on how you want to respond to this person is the sure way you can bring about change. The most likely change is in how you will feel about yourself. I suspect that when this person is rude or picks on you about your stuttering, others will see this and think more poorly of him than you. But, as Scott said, you don't have control over what anyone else thinks, so it doesn't help too much to dwell on that. When I was young, and told my mother that someone didn't like me or was not kind, she often advised me to "kill them with kindness", meaning that I could choose to be kind and respectful to them, regardless of how they treated me. This might result in their gaining respect for me, or it might not. But, it surely would serve to make me feel better about myself, because I treated the other person well. It also lets the other person know that I will not go along with their poor behavior, or be made to feel badly about myself. I'm interested to know how you would really like to act when this person is rude. In your own mind, what would you say to him or do? Taking time to think about some possible responses may be a good first step in changing your behavior. You can take each imagined response and think about what the consequences might be if you were to actually try them. After thinking about that, are there one or two responses or actions that feel true to you or 'do-able' for you? Again, you are focusing on changing YOUR behavior--you do not like being made to feel badly about yourself, so your new responses are intended to help you feel respectful of yourself rather than to make the other person change. You might think of this a 'putting up a shield' so any insults the person tries to send your way hit the shield and fall right on the ground. You are not going to allow them to make you feel badly because of their bad behavior. Please let me know if any of this makes sense to you. I am go glad that you posted this question. Regards, Lynne
From: Vivek
It makes absolute sense Lynne. I really liked the phrase "Kill them with kindness" :). Yes, i think its essential to respond rather than react to the rudeness imparted by somebody to you. Thinking before reacting , Perseverance and Patience is the key which would eventually help me to desensitize myself from such people who intend to attack my stammer. You've very rightly said that instead of trying to change somebody else, we should focus on changing our own self. Building such kind of a shield would do wonders. Thank you for answering my question ever so beautifully. ~Regards, Vivek
From: Lynne Shields
Vivek, I'm glad my answer made sense to you. In your reply, you wrote, "Thinking before reacting, Perseverance and Patience is the key which would eventually help me to desensitize myself from such people who intend to attack my stammer." What a great way to state the process so clearly and succinctly--Making a choice about how you want to view a situation, sticking to the discipline of choosing to respond rather than react emotionally, and realizing that the process of desensitizing yourself to negative comments or actions takes time. I hope others who have this concern will read what you wrote. Beautiful. Thanks!
From: Ed Feuer
Just as all people who stutter (some of the time) are not created equal, neither are the listeners. There are certain listeners for whom stuttering brings out the worst and there is scope for study of that other side of the equation. I think researching the pathology of listeners for whom stuttering evokes a range of aberrant behaviour would be a useful contribution to understanding what PWS (some of the time) are up against. What common elements of personality do these listeners share? What is their psychological makeup? Some quantitative and qualitative research would be nice. So why aren't there such studies? Is it because it's simply easier to blame the "stutterer"?
From: Ellen-Marie Silverman
Hello, Vivek. I've been a little slow, perhaps, to make a comment because, from my perspective, you have been given some very valuable information and practical advice by Lynn Shields and Scott Pialasik, and so I held off. But I think I might be able to make a suggestion that may help you put into practice what they have suggested. So, please bear with me. This may be a little long. /// First, you may have noticed that I have reworded the title of your question from "Reaction" to "Reaction/Response." I did that because I would like to suggest that you consider not reacting externally even though you especially when you may be reacting internally feeling hurt and angry. By waiting while you calm and collect yourself so that you can respond in a thoughtful, considered way, to not react blindly out of anger, resentment, or hurt, you will be better able to do and say what you think will best enhance your standing and contribute to encourage understanding all around. So, I think you may wish to consider responding to slights, slurs, and other forms of verbal abuse rather than externally reacting to them. /// Then to create an over-all framework for dealing with this challenge from those who would bully you you might wish to consider applying the well-known advice often given to people who are afraid to give a talk or verbal presentation because they fear they will be judged harshly by the ones they would speak to. That advice, if you haven't already guessed, is to imagine the people they might speak to as dressed only in their underwear. Seeing them in their more nearly essential form helps remind us they are no better or no worse than we. Recognizing that, we can relax a bit, smile, and feel some basic solidarity with rather than difference from these people. Similarly, seeing those who bully you as people who may be hurting for reasons we do not know and who feel the need to bully to feel good about themselves instead of continuing to suffer may give you a sense of how to relate to them that may allow you to feel like the powerful person you are and them to feel accepted, which is something they may want most desperately to feel. /// In sum, Vivek, we can only control ourselves. That doesn't mean putting on an act. It means recognizing we have many options to present ourselves as the strong, powerful people we are that show their real strength by being a presence that calms and uplifts others. /// I know what I've said can sound somewhat abstract or airy-fairy, but I know it to be practical and true because I've lived it. My very best to you, Vivek, Ellen-Marie Silverman
From: Vivek
WoW! You've summed it all Ellen!! Thanks for putting things into words so brilliantly. Yes i do believe we should always respond to somebody's rudeness even though we react otherwise from inside. Because i have faced situations where i reacted with the kind of emotions it triggered inside and it totally messed things up. So, yes I'll keep this in mind for the rest of my life. I'm gonna kill 'em with kindness as Lynne just said :o) ~Thanks, Vivek
From: Fellow PWS
Here is a little bit of my story before I ask my questions. I was a severe PWS when I was a child and a teenager. In my teens I took a 3 week intensive group therapy program. I came out of that program fluent and as time went on I relapsed never fully recovering from it with a lot of guilt attached. While pondering this in my adult years I came to the conclusion that back then I just wasn't ready to deal with the emotional factor. Between 10-15 years ago I encountered a major setback which was speech related. I had some pretty stressful years following that time trying to avoid that kind of situation again. Itt's just in the past year or two where I was able to make a major turn around with dealing emotionally with my stutter. I went to a stuttering conference and experienced seeing and hearing people with stuttering lead the conference. There is where I realized that I wasn't alone with this anymore and stuttering could be dealt with in a positive way with the much needed support. I started challenging myself with baby steps. I've totally amazed myself time and again with doing things that I thought were impossible two years ago. Actually I've went into situations like what caused that major setback mentioned earlier, successfully. Did I stutter? Sure I stuttered and on about every word too. Did it matter? No it didn't matter to me anymore. What truly mattered was, that I successfully faced the fear. Do those negative emotions come back? Yes they do sometimes, but they don't last as long anymore because I have a support group I stay connected with. Facing the fear has gotten easier now. It is SOOOO liberating to successfully challenge myself!! In day to day situations I hardly stutter but will on occasion. In situations that I don't feel that confident or the situation is stressful I will stutter quite significantly at times. I would like to be able to get more of a handle to manage the physical stutter better at those times. What are some ways I could improve on the physical stuttering in those situations where it manifests itself quite forcibly? What's the time frame that improvement could be well established? What are some of the different directions I can go from here? Ism looking forward to the responses. Thanks for now.
From: John Tetnowski
Dear PWS, Thank you for your wonderful story. I think that I see a few things worthy of mention. You say that when you went to n intensive program years ago, you were not ready for dealing with some of the emotions. Was that really true, or was it that your clinician was not ready to deal with your emotions? I think this is a common problem. Many clinicians are tied to one specific philosophy and all clients recieve a giant dose of that philosophy. I think that the therapy should meet YOUR needs. That being said, your needs may be different and different times in your life. You don't need marriage counseling when you're not married; you don't need physical therapy if you're not physically impacted......but you may need physical therapy some time in your life. Therefore, the answer to your question is partially based on what YOU need today and what YOU are willing to do to accomplish that goal. You also need a clinician that is skilled in many aspects of treatment that is willing to partner with you. Working with that clinician is the best way to figure out what to do and to get an estimate of the time involved. Thanks for the question, and please, keep getting the support from other PWS that you need. John Tetnowski
From: Fellow PWS
Thank you for the feedback. Your question that maybe the clinician wasn't ready to deal with my emotions was a totally new thought to me. It got me thinking on a different perspective of viewing this topic which now gives me another dimension to the whole picture making it clearer. What I remember of the intensive program, there was very little work done on the emotional side of it. Despite that, it was a great program to go through. Looking back over some of the material I got back then, they did suggest self help groups. In the area I lived there were no such groups available. That is just one of those things life sometimes deals out. Even though my family and friends were supportive, looking back I feel maybe I needed more emotional support by someone who really "got it" as a PWS. The relapse came and I regressed after that. Due to this situation and the very daunting aspects of dealing with stuttering as a whole, I think I just gave up. I don't think I was really willing or ready to face dealing with my stutter on a daily basis. Now as an adult that has learned a lot (& is still learning) finally was able come to terms in dealing with the stuttering emotionally by attending stuttering conferences. Now I feel like I am set free and it feels so good!!! To me the biggest part of dealing with stuttering was facing the fear head on. Now I can start working on the physical aspects. Thanks for the great suggestions and advice!
From: John Tetnowski
Thanks for your response. I also want to add that t are now many on-line support/self-help resources. So even if you do not have a local chapter, there are other ways to get some of that support. Sincerely, John T.
From: Tim Mackesey, CCC-SLP, BRSFD
Just evaluated 38 yo female with no history of stuttering before 9/18/12. She had a dystonic reaction to antibiotic Ancef. She stutters on every syllable of every word. It is a 1-2 cycle repetition. She is dealing with reactions from listeners- like a pws. Anyone seen this before? Sad indeed.
From: Gary J. Rentschler
Tim, I've worked with a few adults who began stuttering after a drug overdose or in response to a new medication they began taking. The overdose patient was only minimally aware of his disfluencies, but became concerned about them as others commented on his speech. Our therapy began by developing his awareness (while trying not to attach negative labels to them). He became better able to manage his disfluencies with therapy. His disfluencies differed in that they often came in the middle or at the end of sentences. Other clients began new drug regimens for unrelated problems and started stuttering as a side effect of the new med. Resolving the other issue with medication was the bigger problem, so the clients continued the meds and continued stuttering. The clients learned to manage (but not eliminate) their stuttering fairly effectively. The reactions of others led to them becoming embarrassed by their speech, which both complicated treatment and motivated them. Best, Gary
From: tim mackesey, ccc-slp
Thanks Gary. I am pleasantly surprised to tell you the woman is responding to fluency shaping in oral reading and picture description. We are looking at variables that increase her rate (emotion, etc). I once helped a TBI lesion to striatum region who had stuttering on every syllable. These adults with sudden onset of stuttering are fascinating because they can develop the "identity of a stutterer." The acute pws deals with listener reactions, facial expressions, etc. It is reminiscent of a school age child (perhaps 3rd grader) who was unscathed for stuttering before questions, teasing, etc begins that "stutterer identity." This helps explain why I am such an advocate for early intervention.
From: Lisa LaSalle
Interesting case, and glad to read that she is responding favorably to Tx so far. Since it sounds like a type of neurogenic stuttering, medication-related onset, have you checked out "What we know about neurogenic stuttering - etiology, diagnosis and treatment strategies by Kathrin Koenig (Germany)" in the section below? Kathrin provides some great Tx suggestions. I also wonder about the transient aspect of stuttering in these types of cases, and haven't encountered any myself, just read about them.
From: Tim Mackesey, CCC-SLP, BRSFD
Thanks for the feedback. One interesting facet I have seen in neurogenic stuttering is the consistency within the patient (i.e., a chronic pattern that appears redundant and predictable). In typical development of stuttering there is such variance related to the degree of struggle and/or anxiety. This poses endless questions about stuttering and the brain. If brain responsible like TBI or neurotoxins, why such variability in all the other cases?
From: Walt Manning
It is unfortunate if the clinicians you know are afraid of focusing on the nature of stuttering. I work hard to get my students to focus on stuttering and become desensitized to putting stuttering in their own mouths as they engage listeners in their daily activities. I want them to be able to lead the way in showing their clients that they can give themselves permission to stutter and play with different, more effective ways of stuttering. In the process fluency shaping concepts are incorporated and the eventual goals of the process include enhanced fluency and better communication. But the process isn't going to get vary far if the clinician doesn't lead the way by, as Van Riper said, "Touching the head of the snake."
From: Ari (Israel)
Thanks Dr Walt!
From: Jon Reilly
Hello, I'm currently a graduate student at Kean University conducting a thesis regarding "education on stuttering." I was curious if you could recommend any studies that tested the knowledge of PWS on basic facts about stuttering. I researched and found John Van Borsel, but he presented surveys to the general public. I'm looking for PWS. Thank you in advance for any assistance you can offer.
From: Ken St. Louis
Jon, Using the POSHA-S, a measure of public attitudes toward stuttering, but given to stutterers or parents of stutterers, colleagues and I have found that these groups have much better than average knowledge (i.e., beliefs about traits & personality, who should help, causation, and life potential). Their self reactions (to a hypothetical person who stuttered) are also much, much higher than average. Their Overall Stuttering Score (mean of the Beliefs and Self Reactions subscores) are among the highest we have seen except for a sample of people who stuttered or used to stutter who were found by my students. That is, they were not seeking treatment, and some never did. If you would like to contact me off line, feel free to do so. Ken
From: sachin (TISA)
In my experience in India - many pws, even after having been in therapy many times, still do not know many basic facts and discoveries about Stuttering. Interestingly, many trained SLPs in India, sincerely believe that stammering is a purely Behavioral/ psychological problem. They discount stuttering genes and CT scan brain study results, at best, as experimental guesses.. As a result, their young clients are often under pressure to stop stammering "if I could just stick to the technique". sachin (TISA)
From: Mark Bulger
Jon - I highly recommend getting hold of Marcel Wingate's Foundations of Stuttering. He has a chapter on the 'facts about stuttering' and one on what he calls 'an excess of testimony,' referring to the subjective knowledge of stutterers. The latter chapter has subheadings 'They know not what they do,' 'Nor how often they do it,' and 'Nor when they don't do it.' Not exactly what you're looking for, but I think it would be very helpful for background.
From: sachin (TISA)
In India, cost of formal therapy (by any SLP, fluency specialist or not) is prohibitive. And since relapse is very very common- many of us feel that such therapy is not cost effective, in comparison to therapy for Bronchitis or Tuberculosis or even self-help. I want to know, who pays for therapy in USA and other countries? The client? some insurance company? The state? Thank you very much.
From: Lynne Shields
Dear Sachin, The cost of therapy and who pays for it will vary across the United States. For children attending publicly funded schools, therapy is provided to them, if they qualify for services, at no cost, since the schools are tax-payer supported. Some private insurance companies will pay for treatment, at least for a set number of sessions, while others will not. So, some people must pay out-of-pocket for therapy. Therapy costs often vary by region, and also depending on whether the clinic is not-for-profit or for-profit. University clinics typically provide therapy services at reduced costs, since they are training students to become speech therapists. I hope this helps in answering your question. Regards, Lynne
From: sachin (TISA)
Thanks Lynne! Yes, that helps to understand the therapy scenario in states. In India, it is always "out of pocket". Stammering is not covered by Indian disability act. Yes, state run hospitals will offer speech therapy for a small nominal fee. We recommend these Government hospitals in our self-help groups for that reasons..
From: Lynne Shields
Sachin, Thanks for sharing information about how therapy is paid for in India. It is a good discussion to have with parents of children who stutter and adults who stutter, since it can be quite confusing to try to locate appropriate treatment, as well as to understand the process of seeking affordable services. Thanks for your question. Regards, Lynne
From: Jack M.
Hey all, I'm really curious what the effectiveness of delayed auditory feedback devices are in the stuttering population. I understand there are studies that show DAF can be effective in reducing the percentage of stuttered words by up to 70-80%. Is this correct? More importantly, is there are research that shows the effectiveness of DAF on the population (i.e. DAF is effective for approximately 70% of stutterers?) Curious, let me know! Thanks :) Jack
From: Nan Bernstein Ratner
This one is rather easy to examine by going to a source such as PubMed and searching the published literature. While most studies show that a proportion of people reduce stuttering under altered auditory feedback, in a lab situation, and typically only involving reading aloud, the few more ambitious studies that have tracked usage of such devices out in "the real world" have found very poor rates of continued improvement over time and across the more typical types of speaking situations we engage in. There are definitely a few individuals (if I average across some studies I have seen, I'd estimate maybe only 1/5 or even fewer) who really do profit from using such devices, but they do not appear to be the majority of individuals who have tried the devices for everyday use. And we have no data on use by children at all.
From: Charlie Healey
Hi Jack. Many people who stutter can achieve quick and immediate increases in fluency when speaking in the presence of a delay in the auditory feedback. The effects can vary from person to person but usually the percentage of improvement is quite high particularly when the delay is 200-250 msec. The delay speed is an important variable to consider when seeing how much fluency is achieved. However, one thing to remember about DAF or any other form of altered feedback is that the effects tend to temporary. So, yes, DAF is effective in reducing stuttering in the population of people who stutter but the effects are not long lasting unless there is a gradual process of shaping the fluency achieved with the DAF device to having the person who stutters learn how to adopt a similar pattern of speech without the device.
From: Walt Manning
I have found that the best (and maybe only) reason to use DAF is to help the speaker to focus on proprioceptive feedback - HOW they are speaking and HOW that are using their articulators and vocal tract from the lungs forward to produce easy, more forward-moving and eventually more fluent speech. Most professional speakers, singers and athletes monitor their performance by the movement and "feel" and less by the sound or output.
From: Ken Logan
Based on my experiences, many (but not all) people who stutter experience some facilitative effect from DAF. The extent certainly varies across individuals. I don't have precise numbers at my fingertips, but for some people the improvement in fluency can be quite substantial. The real question, to me, is how long the facilitative effects last. Just to echo (no pun intended!) Walt's comments, I see DAF as a catalyst (perhaps only short lived?!) for changes in the speech articulation process. It may, as he suggested, promote greater reliance on proprioceptive monitoring and/or possibly greater reliance upon auditory or tactile feedback. Some recent research with typical speakers has examined the effects of certain physical and acoustic "perturbations" upon the neural activation patterns associated with speech production. Not surprisingly, when a speaker's feedback system encounters something unexpected or unusual (e.g., a mechanical constraint upon movement of the jaw; suddenly hearing one's voice played back at an atypical pitch), certain neural pathways that had been "quiet" suddenly become active...and the process of speech production is thought to change from a state of running on 'autopilot' to running in a more actively planned manner.
From: Ora McCreary
I wonder why there's no reference at all to drug therapies / pharmacological remedies in this conference - at least none that I can find. Obviously there is as yet no "magic pill" for stuttering. But there is certainly some activity in this realm, notably Jerry Maguire's work and the pagoclone trials. Can you help me contextualize this type of therapy for stuttering? How does the SLP community regard the attempts to find drug therapies? Are drug therapies considered fringe therapies, outside of the mainstream? Is there any reason for optimism that drug therapies will eventually be successful?
From: Lisa LaSalle
Hi Ora, It's a complicated topic, but I had the awesome opportunity to hear Dr. Gerald Maguire present at Cal State Fullerton Stuttering conference last year on this topic. He is a psychiatrist at UC-Irvine and a person who stutters, with 15-20 years of researching stuttering and meds. Check out http://stuttertalk.com/?powerpress_pinw=2643-podcast as a starter.
From: Nan Bernstein Ratner
Even the researchers in this area (Maguire is the obvious best example) do NOT believe that stuttering will be FIXED by drug therapies, only that the frequency of behaviors may be lessened somewhat. It is very clear in all published work that no one believes that a pharmacological agent will make conventional therapies obsolete, only potentially more effective.
From: Ora McCreary
Lisa and Nan, Thanks so much for your comments. However, you have not really addressed my central question: why does there appear to be so little interest in drug therapies among the SLP community and in conferences like this? Are drug therapies outside the mainstream? If drug therapy was considered a promising approach, one would think that mainstream SLPs would embrace it more, not as a cure, but at least as another tool in the arsenal. But there seems to be little interest or attention to this type of approach. I wonder why.
From: Lisa LaSalle
Ora, Thanks for re-stating your question. I would argue that there *has* been interest in this area in recent years - see pp. 376-379 in Nan's & Oliver Bloodstein's co-authored Handbook on Stuttering (2008) and Yairi & Seery (2011), Guitar & McCauley (2010), etc. and new drug therapies that as Nan says only shows a reduction in severity from baseline, but still might be worth the risks for some individuals who stutter. Why are drug therapies not more popular among SLPs? Perhaps simply because we don't prescribe them - we would refer to those who do, if and only if there is a real interest in this option from an older client who stutters.
From: Ari (Israel) geashono@gmail.com
Do you think that the differences that the researchers found ,in the stutterers brain images vs Fluent brain images, are the cause of stuttering or the result of living with stuttering? I figured that stuttering is a complicated disorder and almost all we see and hear on stuttering is not the core problem but the way the stutterer choose to cope with the problem. For instance, the tension ,the "moving back", the blocks in the vocal chords and more ... So maybe the differences the researchers found in the brain images ,are also the result of living with the fear to talk, the result of adopting talking in a different way in order not to stutter. What do you think?
From: Jean Sawyer
Hi Ari, you have posed a great question and one that researchers have been grappling with for a very long time. Soo-Eun Chang from Michigan State University did a study of school age children who stutter when she and I were students at the University of Illinois. She found that these children had structural differences in their brains as compared to children who did not stutter. Specifically, they had less gray matter in left speech motor planning areas, and less white matter connectivity between auditory and speech motor areas. She is now working to image younger children, so we'll look forward to finding out more in the future. A recent summary of neuroimaging studies by Deryk Beal at Boston University pointed to speech processing differences in brains of preschool children who stutter. More research needs to be done, but there is a body of evidence pointing to organic differences in brain functioning in stuttering, even at early ages. And I do believe that living with stuttering for a number of years results in changes in brain processing as a result of stuttering, too. As you and others have correctly pointed out, there is much to be learned about this complex disorder. Best, Jean
From: Ken Logan
Just to add to Jean's reply, I think it could be some of both. That is, in, say, a teen or adult, some of what is seen may be reflective of differences that have been present since early childhood (and perhaps associated with cause), and other things may be reflective of adaptative or compensatory strategies (effects).
From: Ari (Israel)
Thanks for your responses! The problem is that I don't sure how much time it take the brain to change. So it could be that even small child when he change his speech because he stutter, his brain is also changing. So to check it, we need to scan children before they start to stutter or to check children or adults who were recovered from stuttering. I know how difficult it is, but stuttering is very complicated disorder, and today there are Pro that works on drugs to fix the differences they found in the brain scanning ,and I afraid that they are on the wrong road.
From: Nan Bernstein Ratner
A lot of what we were told years ago about brain structure and function has been changed by recent advances in brain imaging (both functional and structural). Learning clearly changes functional activation patterns, and can be presumed to do so very early, although it is difficult to image young children at onset of stuttering for a host of reasons, including their inability to do tasks and remain still. Recent findings of structural differences between people who stutter, recovered stutterers and typically fluent speakers would seem to imply that brain differences are present before stuttering starts, BUT, this may not be true, either, because brain activity/training can even alter brain anatomy. If you have the opportunity to view or purchase the SFA video featuring Martin Sommer, who works in this research area, I highly recommend it. Finally, lots of emerging work, such as studies reported by De Nil and colleagues, and Katrin Neumann and colleagues, show "normalization" of atypical brain activation patterns following stuttering therapy that produces durable fluency in patients. So, our brains are not cast in stone, nor wired intractibly; learning can change us.
From: Ari(Israel)
Thanks Nan for your answer. I suspect that the stuttering therapy wont progress from the new trend of "Brain images."
From: Columbia, SC NSA Chapter
During tonight's group, one of our members asked how consuming alcohol impacts speech fluency. Can some of you please weigh in on this? FYI, a few of our members may conduct research on this topic after the meeting...
From: Kevin Eldridge
Dear Columbia folks, Did you end up running a research project after the meeting. When I first beginning to use fluency enhancing strategies (i.e tools) to be more fluent, I found that drinking alcohol resulted in my NOT being able to use these strategies as well, and hence I stuttered more. At that time I required a fair amount of cognitive resources to monitor my speech and self-regulate. At this point I "just talk" and don't' notice a difference. Though I must admit, I rarely have more than 2 beers or glass of wine. I have heard that many PWS have an opposite effect. I'd be curious to hear the ratio of help to hinder in your group. Cheers!
From: Ken Logan
This is an interesting question. Based on what I've heard from talking with many people who stutter over the years, the effects are variable. Like Kevin said, some report improved fluency and some report the opposite. Also, within speakers, effects may vary over time. I've heard of cases where alcohol had a facilitative effect for a period of time, but then months later did not (and vice versa).
From: Lisa LaSalle
College student clients who stutter who share that when they get tipsy (I don't ever really want to hear about anything beyond that level) they stutter *more* frequently, is of interest. Some of these clients share that they word-switch, and so when tipsy, their "guard is down" and they are more likely not to bother to word-switch. I've heard the same from adults who stutter who are trying to use fluency shaping or stutter mod techniques. That because technique use requires vigilance, it is hard to keep that vigilance going when drinking alcohol. But drinking is often confounded by loud background noise in a bar/pub, etc. which can also increase or decrease stuttering frequency and/or severity. Have there been any research studies on this topic? I am not aware of any.
From: Retz
Interesting question! Perhaps going to an NSA Convention and attending the nightly group gatherings of older adults who stutter and/or college age young adults who stutter might offer some insight, as well as an opportunity for evidenced based research...;-) !
From: John Tetnowski
I agree with Kevin, Ken and Lisa. This topic has come up at our local group. One of the attendees said that he regularly used alcohol and other depressants to help him with his stuttering (e.g., less anxiety). He discussed this openly. The unfortunate thing is that he did not show up for several months after this discussion after receiving his second DUI. JUST A WARNING! John T.
From: David Shapiro
Hi Colombia folks, I don't know of research directly addressing this topic. Anecdotally, however, some clients have told me that they become more fluent with a little alcohol, some become less fluent, and some experience differing reactions at different times (the same person may become more fluent at one time and less fluent at another time). Given the diversity of influences on and within people, the difference observed between and within people does not seem too surprising. Thanks for the good question. David
From: Walt Manning
Like others I don't know of any real research on this issue. When I was at Nebraska we did do some pilot work on the topic using a blood alcohol meter from the police department. As others responding to this question have described there was great variability for all the PWS who were involved, some stuttered more, some less. The only consistent finding was that everyone laughed more.
From: Tim Mackesey, CCC-SLP, BRSFD
I have lost count of the college age patients who have asked me why they are more "fluent" when under the influence. UNINHIBITED. A head buzz can make pws temporarily 'forget' about the role of stuttering in his life. He may have reduced fear and anxiety. UNINHIBITED. I found that as I learned motor controls (i.e. light contacts) staying in control of my speech was MORE difficult when inebriated. Clearly, alcohol and drugs are not a solution.
From: Katie Luthin
I know bullying is commonly seen with children and adults who stutter. What is the best way to support them a child that is being bullied? What if they are uncomfortable to tell their family that they are being bullied, but they tell you. Are you responsible for letting the family know, or do you honor what the child wants and keep the information to yourself? What is the best way to handle that situation?
From: Lynne Shields
Hi Katie, You have asked some very important questions related to handling teasing and bullying. There are some really fine pieces on teasing and bullying and how to handle it on The Stuttering Homepage as well as in the archived previous ISAD conferences. I would encourage you to search there to find more information. Search for information from Bill Murphy, Scott Yaruss, Nina Reeves, and Marilyn Langevin, just to name a few. My basic take on this is to work with the child or adult to find out what is happening and how that makes them feel, and then begin to help the client sort out what they would like to change about the events and feelings. I come at the issue from several directions. First, I would like the person to be able to see that the person who bullies is the cause of the problem, not the person who stutters. I want the client to see that they did not cause the bullying because they stutter---they just happen to stutter and the person who is bullying them has the problem. This is often a quite new way for someone who stutters to look at the situation. Second, I would like to see the client figure out ways to respond to teasing or bullying so that they feel empowered rather than victimized. Identifying how they currently respond to bullying is often a first step, followed by analyzing how those responses work out and make them feel, followed by brainstorming new ways to respond that they want to try to substitute for their old responses. The client can try out some of the new responses, evaluate the outcome, and make changes if desired. There is no easy fix for teasing and bullying, but with some guided effort, children and adults can learn to react to such situations in ways that allow them the freedom to stand up for themselves and not accept blame or feel bad when someone tries to intimidate them. Your second question relates to whether or not you should tell the parents of a child that he/she is being bullied if they ask you not to do so. If you have a relationship of trust with a child, it is important to honor their wishes if at all possible. That being said, if there is concern that the bully might act on threats to hurt the child or has already hurt the child, then reporting it to the proper school administrator is likely important, as well as the child's parents. An SLP working in a school setting talk must become aware of the school (or district) policy on reporting bullying of any kind. That will inform the SLP how to proceed in the case of a child revealing an incident of bullying. Others may have a better answer for you. Since I work in a university clinic, parents typically bring their children to therapy sessions and often observe, so they are likely to learn about bullying if a child shares this with me or a student clinician. I encourage open talk between the child and their parents about stuttering; that sort of openness may take some time to establish, but it is important in helping a child manage their stuttering and the associated issues (like bullying) and the family in supporting their child. Regards, Lynne
From: J Scott Yaruss
Hi Lynne - Thanks for your response to Katie's post... I'll just add that Bob and Bill and Nina and I actually have a paper in this year's ISAD conference on bullying... So, Katie, join us over on that thread and we'll be happy to answer any questions! Thanks, Scott
From: Retz
Katie - Terrific questions! I am wondering though - What is your definition of bullying with children who stutter vs adults who stutter? How would the bullying look in each case? In your mind, is "bullying" different than "teasing" between CWS and adults who stutter? Is there a line between the two that you could identify? I look forward to hearing what you think - Thanks!
From: Ed Feuer
What would happen if most PWS (some of the time), their parents and institutional bill-payers read The Treatment of Stuttering, the highly accessible classic by Charles Van Riper? What if they were to compare the ideal in stuttering therapy philosophy and the much, much less than that ideal in what usually passes for stuttering therapy these days? What if they were appalled by the difference? What if, as a result of their new knowledge, they became much more demanding? Could the profession cope?
From: Lisa LaSalle
I'd answer your question with a question. Have you checked out "Digital snake oil: The emergence of online stuttering scams and shams by Grant Meredith and Anthony Gunn (Australia) Questions/comments" ? re: "what passes for Tx" For what it's worth, I think Van Riper's stutter modification techniques have definitely stood the test of time!
From: Ed Feuer
Lisa, I am not referring to egregious shams and scams as described by Meredith and Gunn. No, I am talking about the deficiencies of mainstream therapy compared with what Van Riper describes in The Treatment of Stuttering. (In fact, Lisa, nobody today does the full regimen of what is described in that book because doing it properly would be labour intensive, time intensive and knowledge intensive.) So with all due respect, I request that you have another go at my questions which postulate a scenario in which most consumers became sufficiently informed to know the difference.
From: Lisa LaSalle
You asked, "What would happen if most PWS (some of the time), their parents and institutional bill-payers read The Treatment of Stuttering, the highly accessible classic by Charles Van Riper?" PWS would learn a lot about Van Riper's take on the problem in 1978. Many of the suggestions may even work for them. But it is not a self-help book, is it? If parents of CWS read it, they would learn some, but re: young children who stutter, there is much more known about risk factors, since 1978, such as from the Illinois project, etc. Institutional bill-payers would likely not read such a text, even if required - don't they make requirements of us? And even if they did read it, again a lot has changed since that time, even tho I agree with the spirit of your question, that much can be learned from it. I will leave it to others on here, to answer the rest of your questions: "What if they were to compare the ideal in stuttering therapy philosophy and the much, much less than that ideal in what usually passes for stuttering therapy these days? What if they were appalled by the difference? What if, as a result of their new knowledge, they became much more demanding? Could the profession cope?" It seems as though you have posed a set of rhetorical questions, and you think there is a problem with "what passes for stuttering therapy these days." So please share what you would like to express.
From: Megan May
I was wondering about the role of caregivers in school-age children who stutter. What should school SLPs be communicating to the parents about their role in the therapeutic process? How much should caregivers be involved and how can they be involved when therapy is taking place in school?
From: Lisa LaSalle
Good questions, Megan. I refer you to the paper by Yaruss & Reeves posted below on the topic of School-age Stuttering Therapy: A burden, a challenge, or an opportunity? In my clinical work, I like for parents of school-age kids who stutter to (a) listen to the messages of their kid first, and if their son or daughter is using some of the techniques learned in Tx, comment positively on that, following their child's lead (e.g., do you care if I comment on your speech in front of just our family, is that ok? In front of your friends? etc) esp important for preteens and teens; (b) help them access online resources re: stuttering - e.g., I've sent some to watch the SFA Swish streaming video Stuttering: By kids For kids or SHP, etc . And (c) parents gently requiring their kids who avoid words or situations due to stuttering to speak for themselves, encourage them to be brave, etc. But I'd be interested in others' responses to your good question.
From: Retz
Megan - You ask a terrific question, and I am happy to share my experience with you! It is as follows: A child who stutters best hope are their parents and a parents best hope is a good professional. When it comes to CWS - regardless of location (university, public school, out-patient clinic, private practice, etc.) - it is my opinion that the therapist must include and motivate parents to be active participants in the decision making regarding therapy and have the parents be active participants in the therapy process; to not do so - to me - is unethical. Hope this helps!
From: Ed Feuer
Hi Retz. You're talking family therapy (or what amounts to it). You also speak of "a good professional." Do you believe that most garden-variety SLPs in the schools are sufficiently trained and competent to do family therapy � and sometimes difficult family therapy? And even if they were, do they have the time? Furthermore, it's necessary not only to bring parents onside but teachers and even classmates. Given those realities, do you see why informed consumers might be skeptical?s
From: Paul Blythe
Why in the twenty-first century are millions of people's lives still adversely affected by stammering?
From: Lisa LaSalle
Maybe because, in the words of Ed Conture (1990) "Stuttering is a multidimensional disorder that has defied unidimensional explanations"? Could we do better? I suppose that is always the case, but I think you have to agree, as you peruse this ISAD and other sites, that we have made great strides in the past two-plus decades, esp re: genetics, acceptance and advocacy, etc.
From: Paul Blythe
LL : Thank you for your reply. What has been done is a good start. Much more still needs to be done (by professionals, governments, pressure groups, etc) to ensure effective treatments are available to all of us as soon as possible.
From: Nan Bernstein Ratner
Do you mean, Why have we not found a cure for stuttering, or why does society respond poorly to people who stutter?
From: Paul Blythe
NBR : Two issues. Quality/effectiveness of treatments and their availability to stammerers. Not all treatments on offer are fit for purpose. Not all stammerers can access treatments. Both issues need addressing urgently and contemporaneously. Needs different people/organizations worldwide to work together with a common aim and timescale.
From: Kate Oeser
A few classmates and I plan to do a presentation to a class of 1st or 2nd graders on stuttering and teasing/bullying. After considering your experiences with stuttering in children, do you have any suggestions for our presentation? How best can we provide information/awareness in order to "prevent" the bullying that might occur in the years to come for a child who stutters?
From: Lynne Shields
Dear Kate, I'm so pleased that you plan to organize a presentation to help prevent teasing. Check out the article, "Practical solutions for dealing with bullying in children who stutter" by Yaruss, Murphy, Quesal and Reardon on this conference for some ideas. There are also guidelines for doing presentations on stuttering in classrooms on the Friends: National Association of Young People Who Stutter and National Stuttering Association websites. Marilyn Langevin at the Stuttering Institute for Treatment and Research in Edmonton, Alberta has put together a program to help prevent teasing and bullying that is available for purchase. Hope some of these resources will help you. Regards, Lynne
From: Sarah Lavieri
Recently I have heard clients give two interesting responses as to what they thought caused their stuttering. One client believes he started stuttering when he was forced to write with his right hand, even though he was left handed. Another client determined that it was excessive tickling that he believed caused his stuttering. What are your opinions on these two potential causes of stuttering? Do clients commonly identify these, and other similar situations, as the causes of their stuttering? If these are not actual causes of stuttering, how would you handle the situation of clients that these were not the cause and explaining actual causes?
From: Lynne Shields
Dear Sarah, Although we are learning much about causes of stuttering in recent years, we don't yet know what causes it for everyone. Even though it is not likely that tickling or a handedness switch actually caused stuttering to develop in the first place, I would never tell someone that they are wrong. Whatever a person tells me that they believe caused their stuttering, I accept at face value. I don't know, for sure, that it did not play a role, even if I have my doubts. And, remember any time when someone has tried to convince you that a belief you hold strongly is wrong; how well did that work out? I'll bet you were not convinced to change your belief. I do believe it is important to educate children and adults who stutter about the disorder, including what we know about causes. I include that within a broad-based education effort that includes learning what stuttering is/is not, how the speech system works, what the person does when they stutter, etc. If a client asks me what I think about their notion of causality, I am honest in saying that (if it is the case) I know of no research that has supports that cause, reiterating that there is much we do not yet know about stuttering. Regards, Lynne
From: Walt Manning
This sequence of posts reminds me that a few weeks ago we had a parent in a diagnostic session indicate that her daughter began stuttering as a result of looking in the mirror. I believe they removed mirrors from the house. As Lynne suggested I also would indicate that there is no research supporting such an idea. I might also suggest that if that was a reason (or tickling, or anxiety in the family, or teasing, or imitation, etc., there would be MANY more people in the world who stuttered.
From: Judy Kuster
I have gathered some interesting information about "folk myths" as causes of stuttering or as treatment for stuttering. You might be interested in looking at http://www.mnsu.edu/comdis/kuster/Infostuttering/folkmyths.html
From: Nan Bernstein Ratner
In medicine, they distinguish between CAUSES and TRIGGERS. I would not ever contradict a parent who feels that something contributed to the onset of stuttering, although as an author of a text, I can tell them that the research has not identified most of the hypotheses I hear (including the tickling stuff), which means that their anecdotal account does not seem to account for stuttering across the general population. However, as in medicine/health, adverse events might very well trigger the manifestation of a problem - many childhood conditions come on after the child has been stressed by illness, for example, even if the illness itself is not suspected as a cause of the disorder. The nice thing about talking about triggers is that it starts a conversation about the most likely best response - many parents feel guilty thinking that something in the kid's upbringing or experiences CAUSED the stuttering. If these things are viewed as random TRIGGERS, then it becomes clear to most parents I talk to that one could not really isolate the child from all possible triggering experiences. You'd have to wrap them in cotton batting, put them on a shelf and deprive them of most of life's experiences.
From: Peter Louw
Dear panel, I wondered if any research is available on the relationship between stuttering and temperature? For instance, do some people tend to stutter more when the weather is cold? In a poll on my blog recently, 9 people said that their speech was worse in cold conditions, whereas 3 said that their speech was better when it's cold. 12 said that temperature didn't make any difference, and 15 said that they hadn't noticed any difference. Personally I find that my speech is markedly better when the temperature is nice and warm, but markedly worse in cold temperatures. I would ascribe this to muscle tension and stress - when it's cold, some people maybe tend to tense their muscles to ward off the cold, whereas when the weather is nice, people tend to be more relaxed. I thought this was rather interesting, but has this been researched before?
From: Ken St. Louis
Hello Peter, Interesting question. I'm quite sure I've never seen a study on the relationship between outside temperature and stuttering. Of course if one did, it would require lots of controls, e.g., humidity, upper respiratory infections, air conditioning, actual temperature differences in different seasons, etc. It looks like your little survey suggests that temperature is probably not a large predictor of stuttering: 23% worse, 8% better, and 69% no difference. That said, you might have a significant difference with a Chi Square which clearly would PROVE that cold weather is bad for people who stutter. JUST JOKING Ken
From: Gunars K. Neiders,
I am glad to see so many familiar faces among the professionals. Finally I have completed a phase of my pursuit of the Holy Grail: To have modern psychology included in the treatment of stuttering. Like in cancer therapy, there has been a resistance on the clients and clinicians part to address the psychological needs that the distress of stuttering has caused, because in their minds they think going to psychologists and/or having speech pathologists utilize CBT/REBT techniques implies that the client is some kind of mental case. In dealing with cancer patients we have overcome the stigma by forming teams between medical doctors and psychologists. NOW THE QUESTIONS: Really this is not meant to be an interrogation or know it all attitude (although it may sound like it), but honest curiosity: How many of you have integrated Cognitive Behavior Counseling and Exercises (such as shame attacking exercises, such as intense, intense voluntary pseudo-stuttering) in your practice? How many of you directly challenge the idea that most people with stuttering hold that stuttering somehow (magically) makes a person less worthwhile? Do you use the General Semantics/REBT approach (may Wendell Johnson lie easily in his grave) that persons are all of equal value (at least to themselves) just because they are alive? I really believe that unless a person with stuttering either by direct means (as by disputing or challenging his or her attitudes) or by indirect means through the general process of stuttering therapy, the environment, the ambiance, the acceptance of the therapist changes his attitudes about stuttering and him or herself the stuttering therapy is incomplete and relapse is highly likely. The main attitudes that need changing are: 1) That one needs perfect fluency; 2) That there is something awful about stuttering; 3) That it is too hard to keep on working on ones attitudes and speech; and 4) Conditional self-esteem tied to speaking success instead of unconditional self-acceptance whether one stutters or not.
From: Lynne Shields
Dear Gunars, There has been an increasing movement in our field to incorporate cognitive behavior therapy, in some form, with traditional speech therapy for stuttering, and for that matter, for other speech and language disorders. Stuttering is not the only disorder that results in the development of negative feelings and emotions. If you search the various journals in which SLPs publish as well as current textbooks on stuttering, you will find many articles referencing the integration of such therapies in stuttering treatment. Best regards, Lynne
From: Judy Kuster
Gunars, you might be interested to know that Dr. Lisa Scott presented a 2 1/2-hour professional workshop Application of Cognitive-Behavioral Therapy Techniques to Stuttering Intervention at the 2012 NSA conference. I believe the Stuttering Foundation has a DVD available for purchase as well.
From: Scott Palasik PhD, CCC-SLP
Gunars, It is very nice to meet you! I'm glad to see a licensed psychologist is in on the discussion of treatment with the disorder of stuttering. I have been using the contextual behavioral science approach of Acceptance and Commitment Therapy (the third wave of psychotherapy) with clients who stutter for the past three plus years. I was trained by Kelly Wilson from OleMiss and Bill O'Brien from Bowling Green with respect to the principles of ACT and RFT (Relational Frame Theory). I have found that by utilizing an approach like ACT, clients create psychological flexibility with the language they use by dropping such words as "need", "should" "have to", "right", "Wrong" and defusing language in order to deconstruct self-perceptions.. These language tasks then can help clients lead to changes in external behaviors with the assistance of exploring values and mindfulness practices in order to enhance awareness and acceptance of ALL thoughts, not just ones we as clinicians may want for them. For it takes the appreciation of the suffering and the joy in order to appreciate the whole person. Again, it is wonderful to see psychologists (like yourself) getting involved with the conversation of treatment of stuttering. Thanks for sharing your thoughts. With compassion and kindness, Scott
From: Jessica Uhlir
Hi everyone! As a graduate student enrolled in a stuttering course, I have found all of the discussion threads to be very informative. Through my class and my independent study (examining the relationship between caregiver-fasilaited slow speech and the language of children who stutter), I have become interested in learning about caregiver involvement in stuttering therapy. While it seems that caregiver involvement is common and crucial for preschool-age children, I am wondering how the role of the caregiver changes as the child ages. For school-age children who receive stuttering therapy, are caregivers usually as active in the therapy process? Do those who work with school-age children who stutter find that therapy is more successful when the caregiver/s are involved? And if so, what are the best ways to involve the caregiver/s?
From: Lynne Shields
Dear Jessica, You have asked some very good questions. It is my feeling that parental involvement is quite important in working with school aged children in most cases. There are so many ways in which they may be involved that I won't try to get into all of them. Certainly, it is important for parents or other caregivers to be educated about stuttering in general, their child's stuttering, and ways to manage stuttering. This includes ways that family members may be supportive of their child who stutters. Best practices with school age children who stutter include treating the entire family whenever possible, so the entire focus or responsibility is not on the child, but is shared. There are many good resources for involving family members. At the moment, I am visiting at the Michael Palin Centre for Stammering Children in London, and they have published information about working with families. They have some quite nice resources on their website. That is one of many places to gain great information. There are several other papers on this conference that may give you some great ideas of ways to involve parents. I see much better progress when families are willing and able to be involved. I think it is probably more difficult to achieve family involvement when the child is being treated in public schools, but I know a number of school-based SLPs have come up with creative ways to involve parents, including before school coffees, Saturday family days periodically during a school year, and so forth. Perhaps others will share some ideas about this with you, as well. Best wishes, Lynne
From: Jessica Uhlir
Lynne, Thanks so much for your response. I would imagine that is difficult to get caregivers involved in therapy in a school setting. I like the ideas that you posted though, such as the before school coffee meeting. I wonder how often indirect therapy approaches (teaching the caregivers slow speech and other fluency generating techniques) are used by SLPs in the school. It seems like it would be difficult to get caregivers into the school to train them on these techniques. Have you ever heard of SLPs in the school running training programs for caregivers of children who stutter? I appreciate your insight on this topic!
From: Lynne Shields
Jessica, I have no data on how many school-based SLPs are using parent-centered approaches, but I do know several who do include parent training as part of their treatment for children. There are a number of good resources for treating preschool and early school age children that focus on family therapy. The book, "Practical intervention for early childhood stammering Palin PCI approach"--PCI stands for Parent Child Interaction)by Kelman Nicholas (Speechmark Publishing, 2008) is an excellent resource. Scott Yaruss and his colleagues have some wonderful information on the website for The Stuttering Center of Western Pennsylvania regarding their parent program. Those are just two good resources that you might want to consult. Best regards, Lynne
From: John Tetnowski
Jessica, A recent NSA survey showed that parents have little knowledge about therapy and little contact with SLPs. This is unfortunate. Jim McClure and I are working on this manuscript, but if you want some of the raw data, feel free to contact me. John Tetnowski
From: Jessica Uhlir
John, I think that would be very interesting! In our stuttering class, my group is currently sending out surveys to SLPs in the school setting to see what their experience is with caregiver involvement. However, I think it would be helpful to gain a different perspective on caregiver involvement. My email is jauhlir@ilstu.edu if you want to send me a further description of the data. Or you could post it on here as well! I appreciate your willingness to share some of your work! Best!
From: Mark Irwin
As far back as 1996 a paper in the American Psychiatric Journal (Stein, Baird & Walker) stated that Social Phobia should not be overlooked as a potentially remedial source of distress and disability in people who stutter. Does anyone on the panel screen for Social Phobia in their clients, use CBT or other therapies targeting social phobia and/or liaise with psychologists for appropriate therapy? What is the panel's opinion of the relationship between stuttering and social phobia? In the panel's experience what percentage of clients have social phobia?
From: Scott Palasik
Mark, Good day to you! Nice to meet you and thanks for asking some wonderful questions. As a person who stutters and a professional for several years these questions are great to hear from people. You asked first about screening for social phobia. The OASES is a great evaluation tool that touches on how stuttering maybe perceptually effect individual clients in a variety of social situations, which we could potentially connect with a social phobia. As you can imagine, some people who stutter create fears related to speaking situations (which could be viewed as socially phobic). You'd have to look at the DSM-IV (the new DSM - V is coming out in the next year, however from what I hear this is going to be a challenging version for many reasons). Anyway, stuttering definitely has a social communication component to it. In therapy I utilize a form of psychotherapy called Acceptance and Commitment Therapy (ACT- pronounced as one word and not separate letters). This form of cognitive behavior science is all about developing behavioral flexibility (both cognitive- internal an d physical-external) by touching on six principles of: mindfulness, acceptance/willingness, cognitive defusion, self as context, values, and committed action related to values. Unlike classical CBT, ACT creates a conversation between the client and clinician where the client is NOT told what they "have to do." It also allows the client to touch and accept ALL thoughts as a part of a whole. The great thing about current CBT practices is that they are becoming more ACT like by including discussions of values of the client while still utilizing the components of situational exposure therapy thus allowing the client to think and feel whatever surfaces, while not telling the client how they "should" feel. ACT helps the client to create options within their own language as it relates to values and ultimately living a valued-based life. ACT is concerned with the WHOLE person and making sure they can develop willingness skills to sit with suffering as well as sit with joy (we all have both and they are both important for growth). Anyway, this is the LONG winded explanation. Please ask more questions! With compassion and kindness, Scott
From: Barbara Amster
Hi Mark Great question! I agree with Scott that "some people who stutter create fears related to speaking situations (which could be viewed as socially phobic)." I believe that CBT is helpful in treating individuals with either or both problems. Evelyn Klein and I have given the Lieberman Scale to many of the clients we worked with who stutter as well as the OASES and we strongly believe that CBT is very helpful. Evelyn is an SLP and a licensed psychologist with special training in CBT so I agree that working with psychologists is a good thing. However, I also believe that most SLPs can learn to effectively use CBT in treating people who stutter. Best Regards, Barbara
From: Kevin Eldridge
Mark, I routinely use screening tools for Communication Apprehension that were recommended to me by my colleague and good friend Michael Retzinger. I have found these to be a very informative part of my initial evaluation, "Communication Apprehension, Avoidance, and Effectiveness, 5th Ed." by Virginia Richmond and James McCroskey. It deals with communication apprehension in the general population, not just with PWS.
From: Scott Palasik PhD, CCC-SLP
Mark, As you can see there are many options for SLPs with respect to doing counseling (CBT, ACT, Interpersonal Therapy, and more). It really can come down to what the clinician is comfortable performing and, more importantly, what the client feels is beneficial to them. Remember, the client is driving the bus, we are just a subtle guide. We don't tell them what to do, we listen and watch behaviors and let them lead the way to their recovery (what that means to the client) by posing questions, sharing thoughts, and creating an open forum for growth and discovery. Do you research, find an approach your comfortable with and do what you can. Great conversation! With compassion and kindness, Scott
From: Ed Feuer
Mark asked a direct question: "In the panel's experience what percentage of clients have social phobia?" He did not receive a direct answer. Assuming that social phobia is extreme shyness on the continuum from shy, it is wrong to automatically associate shy anywhere on the continuum with stuttering. A very common error. There are many, many, many more people who are shy than there are PWS (some of the time) and the former do not do what a qualified SLP calls stuttering. And there are many PWS (some of the time) who are not shy. Those of us who are not shy may be more reticent because of memories of adverse consequences of our stuttering but we are not shy - and we know it (see Van Riper, the fragmented self). But do SLPs know it? And that gets us back to Mark's unanswered question . .
From: Mark Irwin
Thanks Ed for speaking up. (personally I can't blame shyness, only "busy'ness). Yes while I thank those who replied it would be nice to have answers to all my questions. (however I understand others are busy too). While acknowledging the well-meaning and caring nature of SLPs it seems from the very low numbers of pws ever being diagnosed with social phobia, that pws are being denied access to effective evidence based social phobia therapies (including pharmaceutical intervention). Also as there are many who stutter without social phobia, then this variability is not being made clear for the purposes of public awareness and research.
From: Barbara Amster
Mark You do raise some good points and I did mean the Liebowitz Social Anxiety Scale. But if SLPs should recognize Social Phobia in their clients, they would have to refer them to a psychiatrist for pharmaceutical intervention as SLPs, at least in the US, cannot prescribe any drug treatment. I think that this highlights the need for close cooperation between SLPs, psychologists, and psychiatrists when necessary and knowing when to refer. Best regards, Barbara
From: Mark Irwin
Hi Barbara, I agree with you completely. And the use by SLPs of screens specific to Social Phobia (like LSAS) would seem a basic starting point. Kind regards, Mark (mark.irwin42@gmail.com and www.stutteredspeechsyndrome.com )
From: Scott Palasik
Mark, Good morning again. It seems (as it was brought up by Ed) that we did not answer a question about what percentage of people who stutter have a social phobia. A simple answer is we don't know. Anyone who says they have a number for this is not being entirely truthful. You have asked some great questions Mark, thank you. Have a great day, Scott
From: Mark Irwin
Hi Scott. Thanks for your reply. There are a number of research articles on this topic inc Stein 96, Liebowitz 97, Kraaimaat 02, and Menzies 08. Suspending the DSM IV exclusion criteria the figures given range from 50 to 75%. (40% if the exclusion criteria is not suspended). However I was wondering what was the panel's experience? Of course it could be argued you would know if you used a screen for Social Phobia. One of the most commonly used is the Liebowitz Social Anxiety Scale (this may have been the one Barbara was referring to. I remember Scott Yaruss told me he uses this as well.). SPIN is another one mentioned by Larry Molt in his 2003? online conference paper.
From: Scott Palasik
Mark, Nice to hear from you again. Yup, those are great studies and good stuff to look at for sure. Again, we don't have perfect numbers (like you said, we might have a possible range from limited research). However in my experience you could qualify anybody with a social phobia, if you look deep enough in time and experiences. I think what you are doing is a good approach. Finding out as much as you can about clients can help assist clients on their journey with stuttering. Screening tools (like you mentioned) can be a great therapy tool and open up doors of dialogue regarding some social fears. Does that make sense? Keep asking questions! Thanks, Scott
From: Ed Feuer
Phobia is defined ultimately as an irrational fear. Concern about consequences of stuttering is not irrational because they can be very real, often resulting in unfair social and vocational discrimination. Those consequences are fueled by the noxious conversational usages of the words stuttering or stammering to connote lower intelligence, shame, failure or incompetence. Proof is as far away as typing stuttering or stammering into Google News. Students in fluency disorders classes are given an assignment to go out into the streets and stores to do pseudostuttering to gain some awareness of what their future stuttering clients face. What usually happens, I'm told, is massive minimization and sabotaging of the assignment. These students, who theoretically possess some enlightenment about the problem, have already been socialized to the attitude that stuttering is something awful and one must not be seen stuttering even if it's "just pretend." Do these students have social phobia? I don't think so. Given the above, the reticence of people who stutter (some of the time) is something which, under the circumstances, is completely normal. Having said that, what I do find irrational is the view held by some SLPs that calls for changes and reforms are simply attacks on the profession to be ignored.
From: Joseph Nsubuga,Easy Speak Association,Uganda
What can you say about cultural practices contracting speech therapy e.g one member may stutter due to being bewitched.
From: Gary J. Rentschler
Certainly social and cultural beliefs can affect stuttering. Some time ago in the United States, stuttering was believed (by some) to be a mental disorder. While subsequently disproven, this placed a stigma on the person who stuttered, often making the impact of stuttering worse. There is no research to support a mental disorder or being bewitched to be the cause of stuttering.. but such social (mis)beliefs do serve to make the problem faced by the person who stutters worse.
From: Ken St. Louis
Hi Joseph, I have been studying public attitudes toward stuttering for about 13 years now. In the Public Opinion Survey of Human Attributes-Stuttering (POSHA-S) which has been administered in 22 countries and 14 languages so far (with 9 more countries and 5 more languages underway). Three untrue causes of stuttering are rated as "yes," "no," or "not sure." Converting the data to -100 to +100 score where 0 = neutral and higher scores reflect better attitudes (or in these cases where respondents reject the causes). From nearly 160 samples analyzed so far representing nearly 7000 respondents, the lowest (worst), highest (best), and median sample means for stuttering is caused by (a) an act of God, (b) a virus or disease, or (c) ghosts, demons, or spirits were as follows. (a) Act of God: -82, 100, 63; (b) Virus or Disease: -83, 97, 51; (c) Ghosts, demons, or spirits: 15, 100, 89. So most people reject all three of these as causes of stuttering, but a few do not. Incidentally, the lowest mean rating for Ghosts, demons, or spirits was from a sample of French-speaking Cameroonians (15). The next lowest was a sample of 6th graders in Turkey (38). The next lowest after that was from a sample of students in Kuwait (41). I hope a some data will help you make sense of the suggestion that witchcraft is associated with stuttering. Ken
From: Joseph Nsubuga, Easy Speak Association, Uganda
Dear Ken, Thank you very much for your informed reply! The way you have answered my question is a true reflection on man,s quest for causes of stuttering and so you are sport on the statistics!! Joseph
From: David Shapiro
Hi Joseph, I think you would find the proceedings from the 1st (Cameroon, 2005) and 2nd (Burkina Faso, 2008) African Stuttering Congresses most relevant to your question. Also, in previous ISAD Online Conferences, different people who stutter and who live in Africa have contributed excellent papers addressing the assumptions and practices of indigenous healers who treat people who stutter. Feel free to contact me by email and I could provide specific references. I am away from home and am finding it difficult to access those references now. Feel welcome to follow up. I hope all is going well with you since we visited at the IFA Congress in Tours, France. David
From: carlaannstorino@gmail.com
My son who is a 17 year old junior in high school is not participating verbally in his classes. In discussing this with my son and his teacher I learned that he is not participating in part because he is concerned that he will not get the words out correctly. My son tells me that this has been a problem since freshman year, especially in his Spanish class. My son received speech therapy in his younger years through the end of 4th grade. This therapy was for articulation only. What can I do now to determine if my son has a stuttering problem or is he just not confident due to the experiences he has had from freshman year till now. Thank you.
From: Lynne Shields
It may be helpful to consult an SLP who has good experience with stuttering, as well as with other types of communication disorders that might result in reduced participation on the part of the person. A comprehensive assessment, including detailed interviews with your son as well as you may tease out any speech/language issues that may be present. There are lists of fluency specialists available on the Stuttering Foundation website and the Specialty Board on Fluency Disorders. Best regards, Lynne
From: David Shapiro
Hi Carla Ann (?), I see that Lynne gave you some helpful and practical advice. You son's school may already have a speech-language pathologist (SLP) who is qualified to work with people who stutter or access to such an SLP. Let me just add that it seems like you already are doing the right thing - You are talking with your son and his teacher. You are giving your son an opportunity to share with you; every burden is lightened by virtue of being shared. While professional help indeed is available, there is no replacement for being available as a parent. Keep talking with you son. Kindly, DAS
From: Pamela Mertz
I consider myself to be a fairly well adjusted, confident stutterer, after many years of hiding my stuttering, and denial that hiding stuttering bothered me. These days, I stutter openly and talk about my stuttering often. I understand the complexity and variability of stuttering. Many of my friends remark often how cool it is to see me so comfortable in my skin. ~~~~ So why then do I still have moments when I get so frustrated? Yesterday, I was talking with a colleague, someone with whom I am now sharing an office. He knows I stutter - its not an issue. When chatting with him, I was repeating more words than usual, and experienced more blocking. To the point that in one really good block, I broke eye contact, said "geez," looked away and struggled mightily to get the word out. Why does this still happen to a well adjusted, desensitized stutterer? ~Pam
From: Lynne Shields
Hi, Pam! What comes to mind on reading your post is that variation in the ability to handle 'life' varies from day to day for all of us. We are not always at our most resilient every day. I wonder if your reaction to a harder block in the incident you described just happened on a day when you weren't as tolerant of glitches as you might have been another day. What actually might result in the variation could be a myriad of things that make us less able to cope on a particular day--being tired, being stressed by something else, having a fast-paced day overall, not feeling well, and so on. Whatever the cause(s), when frustration is higher it may help to put it in perspective. Since you typically cope well and feel good about yourself whether or not you happen to stutter, the occasional reaction is just that--an occasional event, a normal variation in your generally quite good attitude about yourself and your stuttering. Regards, Lynne
From: Scott Palasik
Pam! Nice to talk with you. It has been too long! How is Albany? I should be getting out there for the holidays. As for your question. I have to say, the first thing that came to mind was sports examples. Now, I'm not a Yankee fan, however I can use one of them as an example. Right now Alex Rodriquez is having a terrible slump in the playoffs. He, historically, has had challenges in the playoffs throughout his career. Here is a guy who has had one on of the best bats in baseball and yet something happens at the end of the season. What has changed? More pressure? Perhaps. More cognitive behaviors? Perhaps. Think about what you just told us (which was a great description by the by). You said you were having a few repetitions, starting thinking about it more, had some blocks, got frustrated, verbally said something "geez", and become frustrated. Now if we went back to those moments, how many thoughts could you write down that all occurred during this conversation? How many of those thoughts were in line with you being a "confident" person? How many thoughts were in line with you being a "well-adjusted person"? My guess, is not many were in-line with those values of being "confident" and "well-adjusted". Thus creating a conflict which could (could) have created a disturbance in external behaviors of speech. It's funny, I was just thinking about this on Saturday. I gave two presentations in LA and during one of them I probably produced some of the most relaxed and flowing speech I have ever had IN MY LIFE. This was in front of a 100 or more people I didn't know. Yet during one-on-one conversations, just minutes later, my speech was full of stuttering behaviors (and thoughts). I compared the two and realized when I was thinking more about my speech and thoughts related to my speech, it broke down more. When I was thinking about my presentation I didn't have as many overall conscious thoughts and produced a more flowing and relaxed production. It amazes me the power of the language we develop in our minds. Of course, these are just thoughts and ideas. Pam, what a great question you asked! Wonderful, wonderful! There are many potential answers. I loved what Lynne wrote! Good stuff! With compassion and kindness, Scott
From: Pam
Thanks for the thoughtful replies everyone. Even though what all 3 of you said makes complete sense, this is the one issue of stuttering that completely vexes me still! Tonight a friend was over, who also stutters, and he commented, after seeing me get frustrated, "why are you letting this bother you? it never bothers you. You always just stutter." I reminded him I'm human, and that even those of us close to rock-star-dom have human moments, even when around someone we are close to and feel very comfortable with. We talked about it for, likened it to skiing, of course, you have to stop trying to so hard and just let go. But as we know, it's "easier done than said." Hope more chime in here! ~Pam
From: Derek Taylor
I am a graduate student in CSD and I am someone who stutters. I luckily received guidance and therapy from an SLP who stutters some years ago. I believe that as a client, I connected with the SLP because we shared the stuttering experience. Do SLPs who stutter address a client's thoughts, feelings and emotions related to stuttering more than SLP who do not stutter? What are the current approaches to therapy used by SLPs who stutter?
From: Scott Palasik PhD, CCC-SLP
Derek, Good day! Welcome to the field of CSD and I applaud your drive and passion. Being a person who stutters and an SLP I completely agree with what you said about connecting with a clinician who has similar experiences. However I must say this, I know many WONDERFUL SLPs who treat people who stutter who do not stutter themselves. For me, the relationship doesn't have to be with a who clinician stutters. It can more about if the clinician is able to share ideas of suffering. Let me explain. Suffering, anxiety, pain, joy, shame, guilt, loneliness, and more are all thought behaviors (and subsequently emotions) that most people experience in life. Whether those emotions have a perceptional foundation in stuttering or in the loss of a parent, these emotions essentially are the same. So really it is about application of counseling in order to connect with a client. For some people they feel more comfortable with another person who stutters as their therapist. That being said, I've known several people who stutter who felt more comfortable with a clinician who didn't stutter for their own reasons. As long as the relationship is an open and honest experience where both sides share in order to create a dialogue, then success is possible (success of any extent). As for types of treatment, you will find all kinds of counseling approaches and philosophies. I personally use a psychotherapy, contextual behavior science approach called Acceptance and Commitment Therapy (ACT- pronounced as one word). This philosophy is based on helping people become more mindful of their cognitive and physical behaviors in order to move toward willingness and acceptance of all thoughts. It also incorporates a large language component to help clients defuse (or break apart) the language they use that is not in line with their core values in order to live a valued-based committed life. This style of therapy is not telling the client to change, it guides the client to a life style more them, at the core. ACT also encourages a dialogue between the clinician and client where both can share in a treatment session. Thus producing a positive (and natural) connection. If you have any questions on this approach, please feel free to email me personally: spalasik@uakron.edu or scottpalasik@gmail.com . Have a great day Derek. With compassion and kindness, Scott
From: Derek Taylor
Dr. Palasik, Thank you so much for the thoughtful response. I do agree that the element of suffering may be at the heart to healthy therapeutic relationships. I am interested in ACT. Can you define psychotherapy as you use it. I understand this term commonly used by SLPs working with stuttering, how is what an SLP does different from a psychologist or psychiatrist?. Thank you for your interest! Always, Scott
From: Charlie O
A good question Derek! I am a SLP who doesn't stutter and agree heartily with Scott's reply to you. A good clinician is one who can establish an effective therapeutic alliance with the person s/he is working with. There are a couple of articles that relate directly to your question. One was published in the 2008 ISAD conference by Joe Donaher and Joe Klein, "Can a fluent stuttering therapist be as good as stuttering fluency therapist?" Another great article is from Walt Manning, published in the 2004 (Vol. 31) Contemporary Issues in Communication Science and Disorders
From: Derek Taylor
Charlie, Thanks for the reply. I have read much of Manning's work and am familiar with his article you mentioned. I have not read Donaher and Klein (2008), I will look for that. PWS need confident clinicians of all types. I am pleased to know you treat PWS; what setting do you work in?
From: Ari(Israel)
Sorry for interrupt the conversation, but I must quote Dr Joseph Sheehan that wrote in his book: "normal speakers should not become therapists until they have first become stutterers" and a page later "Taking the role of a stutterer, finding out what it is the stutter experiences is the principal way the clinician can overcome the handicap of being a normal person".
From: Lisa LaSalle
Interesting reminder of Sheehan's words, Ari. Also, this point supports why I believe in having my students in fluency disorders classes, (who are mostly normally fluent speakers) practice pseudostuttering in public, and with their clients. It is both desensitizing and good practice for Van Riper's stuttering modification techniques. The students never like the pseudostuttering assignment at first, but they gain powerful glimpses of empathy, never complete empathy of course, of what it MIGHT be like to stutter.
From: Ari(Israel)
Thanks Lisa, It is so great to read the stuff of Van riper and Joseph Sheehan, They just wrote what they believed, even if it wasn't popular.
From: Emily Monteagudo
I am a graduate SLP student with an interest in fluency. I am very curious to know what you might have to say about the topic of choosing (and not choosing) speech therapy. I know so many people who stutter do not choose to seek therapy and instead use other methods of improving their speech and feelings about it. I wonder if anyone could share some of the past experiences positive or negative with speech therapy that have influenced your decisions regarding whether or not to seek or continue with therapy. I'd also love to know if there are things that people who stutter have wished speech therapists would have done differently, or would have understood about them. I'm hoping to incorporate this information into a presentation with some of my classmates.
From: Ken St. Louis
Hi Emily, Interesting questions but a bit hard to answer since there a thousands of possibilities. Personally, I did not have access to speech therapy until after my junior year of high school since there were no SLPs anywhere around during my childhood. I finally decided that I wanted help because I was not very successful at managing it on my own. If you look at the percentage of the 3 million stutterers in the USA who are NOT in speech therapy or self help (i.e., the vast majority of these people), then we could conclude that they don't know about therapy, don't want therapy, can't find a suitable SLP for them, are not bothered by stuttering enough to take the plunge to seek speech therapy, etc. We really cannot say. If you would like to take a look at my paper in the Clinical Nuggets section of this conference, "Help Me Help You...", especially the discussion threads, there are some comments that might help you in your presentation. Finally, just as an example of someone who is not happy with therapy, take a look at stutt-l and the short interchange I just had with a person regarding his conclusion that nothing (!) of any value in speech therapy has been advanced in 70 years. Thanks again for your question and good luck in your career, which I hope will be peppered with much success dealing effectively with people who stutter. Ken
From: Charlie Healey
Emily: I am not a person who stutters but have specialized in working with PWS of all ages for over 35 years. Perhaps your question is directed to those of stutter but I have some insights and ideas about why some PWS seek therapy and others don't. First, stuttering therapy is like other therapies (PT, counseling) in that a person will get out it what they put into it or are motivated to change. Many people like the idea of change but are not willing to make the sacrifices needed to make the change. Other factors include availability of the service, costs, knowledge and expertise of the person providing the treatment. Second, I have worked with several adults who had stuttering therapy in elementary school but then lost interest in the process after high school. In many cases, it was many years later as an adult that the person chose to seek treatment again. It the vast majority of cases, they were ready for therapy because they were at one of the lowest points in their life in coping with stuttering. Those individuals did well in therapy because they didn't let cost, commitment to the process, or defeats or whatever stand in their way of managing their stuttering. Others, seek therapy and are simply shopping for a "quick cure." Those individuals rarely stayed in treatment when they realize that the SLP or the treatment program was going to "fix" the stuttering. I have also seen a number of clients who have failed to achieve much success after going through a focused fluency shaping form of therapy. Only working on speech mechanics will not have any lasting effect unless the SLP help the client work through cognitive and emotional improvements as well. So, the bottom line is that past experiences or current circumstances really dictate whether a person seeks treatment of not. Our job is to be ready to help those who want help and are not simply looking for a rapid elimination of stuttering. When PWS realize that the stuttering may never totally go away, they either accept that and continue to work on managing it the best they can or simply give up and call it quits. There was a paper that I co-wrote with one of my adult clients for the 2011 ISAD conference that addresses this issue. He talks about why he choose to get treatment after some 40 years without any treatment. The client's name was Bryan Melvin. Take a look at that paper and that will give you some good insights into the treatment process from the client's point of view.
From: Gary J. Rentschler
I'm an SLP who stutters. I elected speech therapy because I thought it offered me the most control of the problem with the least "side effects". I didn't start therapy until I graduated from college. I wasn't interested taking medications, getting hypothesized, or using devices.. that's a personal choice for every client, but the critical element for me was that I would be responsible, not something "external"... if I had to place my trust in something, I knew I could trust myself. The hard part was it took a long time.. the things I was asked to do (like stutter on purpose) were very hard -- not physically, but psychologically -- but those were the things that resulted in permanent change. Speech therapy is a harder road to take, but I think offers the best result -- my opinion. I still stutter, but I can't say that it keeps me from doing anything (including making fool of myself, but no because I stutter!). Best, Gary
From: Ken Logan
This is a really good question Emily. As some of the others have suggested, I think it really comes down to a person's level of satisfaction with how he or she speaks. That factor seems to be at the heart of "choosing to work on speech," whether it be through formal speech therapy or through other less formal means. So, in that sense, it really is a personal choice (leaving aside cases where parents make the choice for their children). Regarding personal experiences with speech therapy, I'll speak mainly about my college-era program, as that was the most significant. While in college, I was fortunate enough to participate in a speech therapy program where I learned strategies for regulating articulatory movements (e.g., rate, force of movement). It involved many hours of practice. I found that the things I learned there were *really* helpful at helping me speak with level of smoothness and ease that I hadn't experienced for a long time. Of course, this was not a magic fix by any means. It took *lots* of self-directed practice afterward plus lots of incidental learning through reading and interactions with others who had dealt with the same or similar issues before finally getting to the point where stuttering faded into something that was no longer such a big deal. The process was definitely slower than I would have liked (isn't that how things often go!) and formal speech therapy was only part of the process. Anyway, I suppose the reason I chose the therapy path was mostly by default (it just seemed like the thing to do after the "I'll do it myself" approach didn't work very well at all!) - but also due to the gentle prodding of a friend or two, and a former professor.
I'll just add one more reason that people "choose to enroll" in therapy. I have worked with many college-aged people who stutter over the years. For many of these folks, the primary motivator for pursuing speech therapy has been the concern that prospective employers may react to the their stuttering negatively. So, in many of these cases, it isn't that the person who stutters is particularly dissatisfied with his or her speech (though there is probably some of that)...it is more the person's concern that others (especially prospective employers) may react negatively to it that drives the interest in therapy. Sadly, research supports the validity of this concern to some degree.
From: Kevin Eldridge
Emily, Like some of the others who commented, I am and SLP and a PWS. Like others I went through speech therapy as an older adolescent/young adult. Your question is interesting because it makes me think of the Stuttering Foundations poster of Famous People who Stutter. To my knowledge, most of these folks did NOT engage in speech therapy. So... they demonstrate that stuttering doesn't need to hold one back, but they also raise the same question you ask... Is speech therapy the way to go. Thank you for your participation.
From: Emily Monteagudo
Thank you so much for being willing to share all of these great comments. I personally believe in the possibilities of speech therapy. I also know it's not "better" than any of the other ways that people have taken to become satisfied with their speech. I'm fascinated by the process people work through when making these kinds of decisions.
From: Paul
You always hear people saying stuttering has nothing to do with intelligence. However, I have encountered numerous mentally retarded people who stutter. Especially I have noticed a high percentage of stutterers amongst people with Down Syndrome. Is there a correlation after all? I want to point out that I am a stuttering person myself and have a fairly close relative with Down Syndrome who also stutters. This connection has always made me a bit uneasy whenever I'm in her presence and there are other people around. I'm not looking to offend anyone with this post, I'm just curious as to how things are. Thank you for any responses.
From: John Tetnowski
Paul, The data indicates that the prevalence of stuttering is higher in almost all other disorder/difference groups (except deafness/hearing impaired). Therefore, we would expect (and generally do find) higher levels of stuttering in cases of Down Syndrome and most other conditions that have an impact on cognition/learning. Thanks for the question, John Tetnowski
From: Gary J. Rentschler
Paul, don't lose sight of the fact that there are many very bright and accomplished people who stutter too. Keep a balanced perspective.
From: Charlie O
Paul: An excellent question! As John pointed out, the likelihood of stuttering is increased in individuals with cognitive impairments when compared to those with intact cognition. That being said, it does not mean that people who stutter are more likely to have cognitive impairments (where there is NO correlation). As a matter of fact, there have been recent studies of children who stutter that have shown that they have performed at or above normative expectations in language tasks. It was speculated that early advanced language skills in these children may have placed them more at risk for stuttering. As far as I am aware, the major difference between a person who stutters and one who doesn't is that the person stutters.
From: Ken St. Louis
Paul, Posts by John, Gary, & Charlie provide important perspectives on the issue of the prevalence of stuttering among the mentally impaired population (or whatever the most recent politically correct name is). Gene Cooper wrote a chapter on mentally retarded stutterers in a book entitled "The Atypical Stutterer" which I edited in the late 1970s. In it, he reviewed the extent literature which showed that the prevalence of stuttering (however defined) was three times higher than in the general population. For what it's worth...Ken
From: Nan Bernstein Ratner
The link between "stuttering" and Down Syndrome has been commented on before and appears real, although, given my work on language formulation problems and disfluency, it's not clear to me that all past work has clearly distinguished between canonical stuttering symptoms (blocks, prolongations of consonants) and those disfluencies that overlap with typical, language-learning and language disordered people's speech. Much of the historical info, however, about IQ and stuttering is hampered by old definitions of the "mentally retarded" (current term = intellectual disability)- tremendously varied populations with a number of ante-natal and post-natal brain damage wound up in these groups. Finally, as in language skill, the correlations between IQ and fluency are not likely to be very linear. IQ needs to be quite impaired before generalized effects on anything other than vocabulary are evident. So IQ, which is only a proxy measure of some kinds of verbal/nonverbal function, is likely to affect speech behaviors more below a certain threshold than across the board. Having said all this, we could certainly use more work in this area. best, Nan
From: Peter Louw
Dear Panel, I have always wondered how stress - meaning the rate at which we live at any particular moment in time, as defined by the "father of stress studies", Dr Hans Selye, the Canadian biologist - fits in with stuttering. Some twenty years ago when the issue of stress and stuttering was discussed, SLPs would prefer to use the psychological term "anxiety", but these days more and more do seem to acknowledge that "stress", in the wider meaning as used by Selye, can play a major role in stuttering. For instance, a person may have high levels of stress without having feelings of anxiety. Yet many PWSs still do not seem to be aware of how stress impacts on their fluency. My questions are: Is stress the elephant in the stuttering room? And are stress studies part of the curriculum for SLPs and if not, should they be? Many thanks for your response and kind regards.
From: Gary J. Rentschler
Peter, I'm not sure that many have made the distinction between stress and anxiety. Thanks for making a thought-provoking point.
From: Kevin Eldridge
Peter, First of all, thank you for introducing me to Hans Selye. It ran a quick search and skimmed a bit of the information before responding. I feel that you bring up a very important distinction. I would agree that Stress and Anxiety are very different beasts. If I am understanding the little bit I read (and I do plan on reading more), in Dr. Selye's view, stuttering in itself would be the noxious stimuli that leads to stress. For many adults who stutter, one could assume that they are in the "exhaustion stage" of adaptation secondary to the long term presence of the noxious stimuli (the stuttering). Seyle talks about weakened immune system and biological damage being a result of this long term exposure to distress. I wonder if Seyle would look at it this way, and if he would expect PWS to have such damage at some level. I have practiced Mindfulness for a number of years now, and recommend my clients do the same... as a way to stay in the moment, and therefore decrease the effect of ANXIETY of future events, but Mindfulness work also reduces the effects of STRESS. I will have to think much more about this distinction. // On a personal note, as a PWS (who is also an SLP), I know that when I am stressed (not anxious) I am much more susceptible to speech disfluencies. This was even more noticeable earlier on in my "recover" process.// Thank you once again for introducing us to Hans Selye!
From: Tom
I have a prediction and the future question? What do you think will happen in the next 10-20 in terms of stuttering treatment and research? Are we closer to finding what causes stuttering and eradicating stuttering..... Or perhaps feneral public perception will change. Has public perceptions changed? Any studies measuring public attitudes over time. Thank you.
From: Ken St. Louis
Hi Tom. My crystal ball is currently at the shop for repairs, so I'll leave to others to predict the future.
From: Ellen-Marie Silverman
[[What do you think will happen in the next 10-20 in terms of stuttering treatment and research? ]] Hello, Tom. I have a feeling that others also are asking themselves the same questions you have posed here. Ken St. Louis, for one, and I for another. I am going to respond by stating that I hope those who are or will conduct research relating to stuttering and the consumers of that research pause to reflect anew on what already has been accomplished. >>> Almost, without exception, the research done everywhere in the world has been driven by what you suggested as the desire to find the cause or causes of stuttering problems so as to determine a way, or ways, of successfully managing the problem. And, as you know, there is no consensus based on the findings generated primarily by applying quantitative research methodology. This has led some to feel quite discouraged, and reasonably so, since the goal of discovering how people with stuttering problems differ from those who do not have stuttering problems does not seem to have been realized. But I would like to suggest here that this, of itself, is no reason to feel discouraged. In fact, I will go out on a limb, perhaps, by suggesting that this very same general outcome may be viewed as something as encouraging. The consensus of many interpreting the data that we who have or have had stuttering problems seem to think, feel, and behave in many ways as do people who do not have or never have had a stuttering problem can help us see ourselves clearly enough to be unwilling to adopt the persona of "different" or "outsider." >> Yes. We do stumble, block, or repeat sounds or words sometimes. But this is something we can learn to do with increasing ease. That is the easy part. The harder part for some of us is to recognize we are not different or "special" just because we sometimes stutter forcefully after years of thinking that we were because that is what we occasionally do. But looking at the years and years of research data that indicate we are not fundamentally different from people who do not have stuttering problems should encourage us to live as though we are not, which will help us live fuller, brighter lives. >>> So, Tom, I see a future where we all attend to our similarities at least as much as we do our differences and allow that outlook to guide us all to be fully contributing members of society. >>> Thanks, Tom, for asking this question because I think we need to look more realistically at what we already have done as researchers and clinicians and to apply the conclusions we reach to help create a brighter future. Best, Ellen-Marie Silverman
From: Kevin Eldridge
While I do not wish to predict what WILL happen in the next 10-20 years, I will tell you what I HOPE will happen in the next 10-20 years. 1) That we will better understand the physiological cause(s) that lead to the speech production system of those who stutter to break down under conditions others do not. 2) That we would be able to identify those children who will "spontaneously" recover from those that require therapy. 3) That our understanding of the biochemistry of stuttering will lead to effective drug therapies. While I agree with Ellen-Marie's post about self-acceptance, I would still rather that we found a way to eradicate the need for one to do so. While I can sit back now at age 51 and tell myself that I learned much about myself and others, having been a person who stutters, I would never wish what I went through on another young child. I am hesitant to bring this up in this kind of a forum, where I may be misunderstood, but my hope for the future is that we find the cause, the cure... for stuttering as well as every other disorder that effects mankind. To dream of any less.... I ask myself... Why?
From: Ellen-Marie Silverman
[[While I agree with Ellen-Marie's post about self-acceptance, I would still rather that we found a way to eradicate the need for one to do so. ]] >>> Kevin, your passion to alleviate the suffering of those who experience stuttering problems as children is clear. And I would hope that if you read the series of research papers I authored on the disfluency behavior of preschoolers and on stuttering, especially among women, published in ASHA journals, the Journal of Fluency Disorders, the Journal of Communication Disorders and elsewhere that you will recognize that my passion for preventing stuttering problems is genuine as well. >>> It seems, we fundamentally are on the same page, so to speak. So, I wonder why you referred to a post you say I made about self-acceptance as a seeming counter-point to your vision of the future. I did not make such a post in this forum or elsewhere in this Conference. Not that I don't believe self-acceptance is the bedrock for living a poised, comfortable, and happy life whether or not someone has a stuttering problem but because I did not feel the need to do so. >>> I wonder why you felt you had to establish some sort of contention between what you say I said and what you want to state when, in my opinion, no such polarization was necessary for you to offer your hope for the future. None of us benefit from divisiveness individually or collectively. Polarization is not the path to the greatest good. Cooperation is. I certainly support your hopes of a better life for all children than a life characterized by bullying, ostracization, and feelings of shame. It is mine as well. >>> Perhaps, our shared visions/hopes for the future will be realized as we work together toward that goal. Best. Ellen-Marie Silverman
From: Kevin Eldridge
Alas... this is the problem with posting in such a forum. For I was not trying to be contentious. In fact, I was trying to say that I agree with what Ellen-Marie was saying :) She stated: "The harder part for some of us is to recognize we are not different or "special" just because we sometimes stutter forcefully after years of thinking that we were because that is what we occasionally do. But looking at the years and years of research data that indicate we are not fundamentally different from people who do not have stuttering problems should encourage us to live as though we are not, which will help us live fuller, brighter lives." In my haste to answer as many posts as possible, I may have incorrectly called this "self-acceptance". Which I believe is a good thing. Since I read Ellen-Marie's post as dealing with self-acceptance, I was merely pointing out that I agreed this is an important goal - a key to my own "recovery" I might add, but hope it is someday not needed.
From: Lisa LaSalle
"What do you think will happen in the next 10-20 in terms of stuttering treatment and research?" More genetic advances, perhaps enzyme therapy (ala Dennis Drayna), and certainly more brain imaging of younger children closer to the onset of their stuttering. More attention to risk factors in young children and more longitudinal research that helps replicate what we think we know so far in that area. More acceptance of stuttering in the older populations, due to technological advances like www.stuttertalk.com and www.stuttersocial.com and ISAD archives (!) etc. But as Ken St. Louis alluded to, these are predictions that are loosely formed, not crystal ball insights.
From: Pamela Mertz
A SLP student commented on my paper and asked some questions about confidence. Her comments and insights are wonderful, and I actually need to process her feedback before thoughtfully replying. Part of her question to me is wonderful, so I thought I would post it here too and see what people think. ~~~~~~~~~~ Laurent writes "in being a more confident speaker, do you feel as though your "listeners" recognize you for that? Do you feel that a PWS who has come to terms with his/her disfluency portrays him/herself to society in the same manner as a PWS who is still dealing with internal struggles? Do you think that "inner piece of confidence" is readily recognized by society?" ~~~~~~~ This really resonated with me as a unique and interesting question. Thoughts? ~Pam
From: Lynne Shields
Pam, Absolutely, I agree that someone who is a confident speaker, whether or not they stutter, comes across quite differently than someone who is not confident. Helping a client find ways to build confident is one of the central pieces of therapy when working with someone, child or adult, who has low confidence. Not only does a person who is confident project that outwardly to others, but they also are more likely to participate in variety of situations and activities of their choice, as opposed to hanging back for fear that they might stutter. Appearing confident to others is a positive thing, but it is secondary to the benefit to the person who stutters, to the feeling of freedom and openness in making choices. All the best, Lynne
From: Paul Blythe
Fluent people are uncomfortable with our discomfort. The more confident we are the more at ease are our listeners.
From: Ellen-Marie Silverman
Yes. Our brains seem to be hard-wired in a way to make us empathic, according to Daniel Siegal, author of "Mindsight" and other recent books on mindfulness as a tool to experience greater ease in life. >>> Our tendency to be empathic is yet another example that, in our essence and basic functioning, we are more similar than different, whether we have a stuttering problem or not. Ellen-Marie Silverman
From: Allan
First question is does the speecheasy work, and for what kind of stutterers? Is the rate of effectiveness only 20%? Do very mild stutterers benefit less from the speecheasy. Second, if it works (at least for some stutterers). How come most speech therapists do not recommend or even mention anti stuttering devices to clients and families? To the average person, what is wrong with using an anti stuttering device to alleviate stuttering. Given that adult stuttering is resistant to traditional speech therapy and relapse is common. Thank you very very much
From: Ken St. Louis
Dear Allan, You asked a number of questions. I'll try to answer them at least briefly. >>> Does the speecheasy work? If you mean by "work," Does the SpeechEasy"help" or "reduce stuttering?" the answer is "yes" in some cases, "no" in some cases, and "yes and no" in some cases. >>> For what kind of stutterers? According to Amber Snyder, an SLP who consults for Janus Development Group who manufactures the SpeechEasy device, it can be effective for all kinds of clients. Her 10 years of experience suggests that no one kind of stuttering should be excluded from consideration, although the greatest challenge is often for people whose stutter consists of silent blocks. In such cases, they don't hear anything when they start their stutter so the SpeechEasy may not be as effective at the outset of an utterance. That said, apparently some stutterers with silent blocks find their stuttering to be greatly reduced or even changed while using the device.>>>Is the rate of effectiveness only 20%? This is phrased to be a loaded question for which you probably expect a "yes." I don't believe anyone knows for sure what the long-term effectiveness rate is for the SpeechEasy although I have been following Larry Molt's clinical trial now for about 7 years (I believe). He has indicated that about 50% of his original subjects (who did not need to buy their devices) still gain benefit from them. From several other sources, the long term effectiveness rate seems to be around 50%. But one must be careful to define what is meant by that. The large majority of stutterers in the followup surveys that I have read report that that they found the device useful, even if they don't always wear it. Which measure, then do you take? Some stutterers only use their device on "bad days" or in "harder than usual" speaking situations. It seems to be clear-- although I have not seen good data to support it yet--SpeechEasy clients who engage in speech therapy after the device has been fitted benefit more than those who do not. It is for that reason that Janus Development Group recommends that all SpeechEasy users obtain speech therapy with a trained person after they purchase their devices. I found that to be a responsible position. >>> Do very mild stutterers benefit less from the speecheasy? I don't know the answer to this one. I suspect the answer would be not much different if you were asking about any therapy strategy. Perhaps others on the panel might have additional information. >>> If it works (at least for some stutterers), how come most speech therapists do not recommend or even mention anti stuttering devices to clients and families? I cannot speak for most speech-language pathologists, but I will speculate that you are right that most SLPs do not mention these devices. The most obvious reason is that most are not familiar with the device or that there is no one in their area who can fit one. Another reason might be that the initial cost is substantial, although it recently was reduced. In my own case, I have been suspicious of all types of claims of quick cures for stuttering over the years ("aecanap"'s if you will or "panacea" spelled backwards). Thus, I have waited for nearly 10 years to embrace the SpeechEasy as just one tool that I have to help people who stutter. Just this year, our clinic became a SpeechEasy dispenser, with me as the currently trained person who does the evaluations and followup therapy. I took this step because I have had too many stutterers who simply are not interested in--or are completely jaded about--traditional speech therapy. To date, I have only fitted two devices. One person moved back to his native Saudi Arabia shortly after, and the other person is still in follow-up. I can't judge my own success yet, but in the first case the person was too late to obtain speech therapy and in the second, the person was not at all interested in trying anymore speech therapy, even after I made a strong case for it. >>> I am aware that many on this forum are not fans of the SpeechEasy and may wish to offer alternate answers. For me, it is one more tool that can be used in certain situations. It is not a "miracle cure," and it is definitely not for many if not most people who stutter. Still, with an honest discussion of its pros and cons followed by responsible and competent fitting, early therapy with the device, and good follow-up, I am comfortable prescribing it. I hope this helps. Ken
From: Jennifer Palumbo
Greetings, my question is about adults who stutter and their attitudes about stuttering especially those for which therapy was not successful. Does anyone have any experience with these individuals and do you know how they typically view their stuttering? I ask because my brother is 26 years old and stutters still and has not had therapy that has changed his stuttering. However, he does not view his stuttering as something negative because it has not held him back in his life. I was curious if this was true of other adults, do most just learn to accept it similarly to my brother?
From: Lynne Shields
Dear Jennifer, The experience of adults who stutter varies quite considerably. Some people come to terms with their stuttering and make out just fine, whether or not they stutter, while others may not feel comfortable with their stuttering, with or without having had therapy. People vary in their personalities, needs, wishes, coping mechanisms and in so many other aspects of life that I do not think there could be one answer for your question. I am glad you asked, though, because it brings up the important point that whenever talking with someone about their experience of stuttering, it is critical NOT to make assumptions about what they think or how they feel about their stuttering. I find it best to ask them and allow them to tell their own personal story. Best wishes, Lynne
From: Judy Kuster
Date: 22 Oct 2012
The live, threaded discussion part of the 2012 ISAD online conference is now closed. The conference papers and responses made during the conference will remain online. Thank you for stopping by. Judy Kuster