There has been long-time agreement among speech-language pathologists (SLPs) that it is important to counsel the parents of children who stutter (Bloodstein, 1995; Bloom & Cooperman, 2003; Mallard, 1991; Rustin, 1987; Zebrowski and Schum, 1993). This view has been supported and mandated by The American Speech-Language and Hearing Association (ASHA) in its Preferred Practice Patterns (1997) and Scope of Practice in Speech-Language Pathology and Audiology (2001). ASHA states that we are responsible for both information counseling and adjustment counseling with our clients and their families. However, we have found that many SLPs, who work with the families of children who stutter, are much more comfortable with information counseling, and feel relatively insecure and in need of guidance for further issues in counseling. Luterman (2001) cites a study by McCarthy that demonstrates many SLPs receive no training in counseling. Flahive and White (1982) found that in a study of 226 audiologists, 90% of training focused on informational counseling and 10% on personal adjustment counseling. We do believe that information counseling is important and absolutely necessary for the parents of our children who stutter, and we will briefly examine some of the issues that are most frequently utilized in information counseling. However, the focus of this article is to assist the SLP in transitioning from the role of one who provides information only, to one who feels informed and motivated to learn more about, and to use the skills of counseling in the therapy process with parents.

Conture (1990) notes that a 30 to 60 minute information sharing session, after the initial interview, may be all that is necessary for parents, to relieve their fears and guilt. We agree that for some parents this is true. However, for the vast majority of parents, much more time is necessary to answer the questions of: "What causes stuttering?", "Did we do something wrong?", "Should my child be treated differently than my other children?", "Will my child outgrow this stuttering?" and other pertinent informational questions. Answering these questions can bring a great deal of relief to parents who have carried these concerns for years. We meet with parents weekly and spend one day of our Weekend Workshop providing information counseling for our parents (Bloom & Cooperman, 2002; Cooperman & Bloom, 2002). During this Weekend Workshop, we provide information sessions presented by both professionals and people who stutter. We provide literature from the Stuttering Foundation of America and connect the parents with information found on the Internet: The Stuttering Home Page (http://www.mnsu.edu/comdis/kuster/stutter.html), The National Stuttering Association (http://www.westutter.org/), and the Stuttering Foundation of America (http://www.stuttersfa.org/). We believe that all of these activities are important, and provide parents with valuable information about the cause of stuttering, methods of assessment and directions for families to provide a more stable and productive communicative environment for the person who stutters and the family. However, Luterman (2001) points out that there is a seductive side to counseling by informing. The clinician can appear to be one who has all the answers about the problem. Instead of empowering the parent, the parent comes to think that the clinician or the "doctor" knows best. "This mode of counseling assumes that parents are weak and incapable of effective decision making; people generally conform to our expectations" (Luterman, 2001, p.4). To facilitate the empowerment of parents, we believe it is important for the SLP to integrate the role of one who informs with the role of a "clinician/counselor" (Bloom and Cooperman, 1992).

Crowe asserted "...the question of whether counseling should be essential to the clinical practice of speech-language pathology and audiology is rhetorical. Counseling, in fact, does occur in almost every therapy encounter, whether it is intentionally employed by clinicians to achieve specific therapy goals, or whether it happens spontaneously and unguided toward any purpose." (Crowe, 1997, ix-108). Therefore, we urge SLPs to continue to broaden their thinking, studying and experience with counseling, so that their work with parents might include the guided and informed practice of both informational counseling and the integration of the skills of adjustment counseling. We have named the professional who integrates these roles a "clinician/counselor" (Bloom and Cooperman, 1992). We believe that this title allows us to maintain our primary identity as speech-language pathologists and yet adopt appropriate techniques of the counseling profession as they can assist us in providing holistic treatment to both our clients and the parents of children who stutter.

For a more complete description of counseling and its role in communication disorders and stuttering therapy with parents, the reader is urged to consult any of the following: Andrews and Andrews(1990), Schum (1986), Rollin (2000), The Stuttering Foundation of America (2003), and chapters in Bloom and Cooperman (1999) and Manning (2001).

The work of the clinician/counselor is about helping people to change the way they think, feel and behave in regard to their communication disorder. As SLPs, we must become students of the change process, and professionals who facilitate our clients' inward journey. Our hope is that parents will find the internal and external strengths and personal resources to help them change how they feel about themselves, when necessary, and to accept and relate more fully to their children who stutter. We will highlight, here, some aspects of counseling principles that might enrich the interaction and productivity of SLPs when working with the parents of children who stutter:

• Develop a strong client/clinician relationship. As the clinician/counselor continues to weave information into therapy, he/she is simultaneously transitioning to a new role. A "safe" space is being created where a parent or a group of parents know that they are each important to you, the professional. Rogers (1961) encouraged counselors to enter the client's world as if it were their own. What is it like to be the parent of a child who stutters? We need to learn about our parents from the inside out. In order to adequately do this, we must put aside what we think are the parents' concerns, and invite each to tell his or her own individual story. The pace of this process will be set by the parents. Allow the trust to build slowly. Do not rush the process and do not put words into the parents' mouths. Allow parents to do most of the talking. It is within this relationship that parents will come to discover their own answers. This does not mean that the clinician/counselor is passive. Listening is an active process.
• Be a good listener: Listening is a skill, and it can be learned (Ivey, 2001; Eagen, 2001). There are many micro-skills that contribute to active listening. Once we are committed to increasing our listening skills, we find that listening is hard work. As parents are telling their stories, we must listen with our ears, our eyes and our whole bodies. Look for the emotional responses, for the words unspoken, for the tone of voice or the unfinished sentences. Listen for the signs of grief, sadness, fear, over-protection and frustration that have silently plagued parents. Our silent, but attentive listening allows us to notice many of the telling non-verbal and/or verbal responses that provide important information about individual parent reactions. These reactions need to be validated and will form the goals of our later therapy sessions. Attention is one of the most important of the listening skills and it must be exercised as one does a muscle. Christine Caldwell (2004) states that "Attention is the currency of therapy. High-quality, non-judgmental attention can be a balm directly applied to a client's wound, which soothes immediately and heals over time"(p.35). Luterman (2003) says "The counseling relationship is one in which the counselor practices deep, selfless listening in order to help the client. The act of deep listening requires a great deal of energy and the capacity to focus attention for a long period of time"(p. 19). Therefore, SLPs must make certain they listen to their own needs and responses and provide for their own self-care. We encourage all SLPs to take advantage of workshops which assist in the development of listening skills.
• Help to facilitate self-exploration and awareness Two barriers to client self-exploration are giving advice and premature problem-solving. Giving advice is not to be confused with giving information. Advice is telling someone what you think that they "should" do, rather than leading them to discover and to choose for themselves. It is often the temptation of clinician/counselors to give advice when they believe that it is their job to "fix" the parents. On the contrary, our job as clinician/counselors is not to "fix" the parents but, while using listening skills (Ivey, 2001; Eagen, 2001), to lead the parents to their own discoveries of what is best in their families. It is rewarding to see parents do their own problem-solving and come to their own awareness of what is best for their child and their family. This is how real change happens.
• Make use of family assessment tools Mallard (1991) developed a program based on the work of Rustin ( 1987, 1991) that involves the entire family in therapy. We support this concept and have included "family nights" in our treatment model. These family nights have been most helpful for parents, siblings and children who stutter. We encourage others to do this. However, even when this is not possible, we believe it is important to gather as much information about the family and family relationships as possible. Without this information our therapy is much less productive. Mallard's assessment (1991) includes:
  1. Recent behavior and emotional health: general health; eating, sleeping and elimination; emotions; peer relationships; relationships with siblings; relationship with adults; antisocial trends; sex education; and schooling.
  2. Family structure and History: personal background; parents' family backgrounds; the child's grandparents and extended family issues; home circumstances; and neighborhood.
  3. Family life and relationships: parental relationships; parent-child interaction; child's participation in family activities; and discipline.
  4. Temperamental or personality attributes: meeting new people; new situations; emotional expression; sensitivity.
  We have found that two of the best tools for acquiring this information in an easy, conversational way are the Eco Map and the Genogram completed in collaboration with parents (Bloom and Cooperman, 1999, p.192-201). Both of these instruments are visual ways to learn about family relationships. The Eco map depicts the major systems that are part of a family's life. It portrays the family's "life space" and demonstrates the flow of resources and the nature of family-environment exchanges. It can help to point out the important nurturing or conflict-laden connections in the family. A PDF file of the Eco map is attached with permission of Elsevier. The Genogram, too, is a visual aid, one that assists parents in telling the story of their family history and their intergenerational history. A PDF file of the Genogram is attached with permission of Elsevier. These histories have transmitted powerful commands, role assignment, events and patterns of living and relating. We have found that these tools help us to understand the family and provide a focus for future therapy goals. In fact, while working with a parent recently, we discovered that we had limited insight into the family system until we completed a genogram with the Mom. We also urge clinician/counselors, before working with parents, to complete their personal genograms and eco maps and experience the insights that can be found from studying the visual patterns of their own histories.
• Incorporate group therapy: We have found that utilizing the skills of a clinician/counselor and combining informational and adjustment counseling within a weekly parent group has been most productive. Group treatment provides parents an opportunity to share their feelings about having a child who stutters. Our parent group members have expressed their gratitude for the solace provided by this group experience. Luterman (2001) discusses the curative factors in group process which we observe with our parents:
  1. The group instills hope in its members. Seeing how others have coped provides inspiration that only members of the group can provide for each other.
  2. The group helps individuals realize that they are not alone. This, we think, is one of the primary benefits of group process.
  3. Members offer each other support, reassurance and insights which have credibility few professionals can match and
  4. The group develops a cohesiveness which, itself, is therapeutic. We are so committed to the group process that we have initiated a sibling group, in addition to our child, teen, adult and parent groups.
• Take time for self-care and avoid burnout As you incorporate the skills of a clinician/counselor and help parents to adjust to their life issues relating to a child who stutters, it is imperative that you continue to make choices that keep the helper in you alive. Some believe that burnout is inevitable for helpers; however Corey (2001) believes that we have considerable control over our potential for burnout. He has many suggestions for helpers which might well be adapted as suggestions for parents. Some of his strategies for keeping yourself alive both personally and professionally are: bringing variety into your work; monitoring the impact of stress; attending to your health through exercise, diet, sleep and meditation; taking classes and workshops; attending conferences; reading to gain new perspectives; and finding pleasurable hobbies to achieve a balance in your life. We owe it to our parents and clients to practice self-care. Integrating the professional and personal elements of our lives can contribute to greater effectiveness as a clinician/counselor.

ASHA (1997; 2001) mandates that we provide both informational and adjustment counseling in our service delivery model. In order to respond to this mandate, we must abandon the security of only providing information to parents, and venture into the world of the clinician/counselor. The transition from information giver to clinician/counselor relies upon the commitment on the part of the SLP to develop a new set of skills. We hope that our colleagues will join us in exploring and implementing the counseling literature which must be incorporated into our work with children who stutter and their families.

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Bloodstein, O. (1995). A Handbook on Stuttering, 5th ed. San Diego, CA: Singular Publishing Group.

Bloom, C.M. & Cooperman, D.K. (2003) Counseling and disorders of fluency: An overview. Perspectives, December, pp. 2-6.

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August 23, 2004