The motivation for this essay comes from some recent developments in the American Speech-Language-Hearing Associations Special Interest Division 4Fluency and Fluency Disorders, as well as some recent discussions on the STUTT-L listserv. The past two leadership conferences held by Division 4 have focused on "outcomes" of stuttering therapy. In 1997, the conferees gathered to develop "outcome statements" from a number of perspectives: i.e., the client, the clinician, the family, society, insurance companies. The goal of the 1998 leadership conference was to take those statements from 1997 and develop them into 7-point scales that could be used to measure "functional outcomes" of stuttering therapy.
I was involved in both of those conferences. When we broke into small groups during these meetings, the people in the groups that I was a part of all seemed to understand that we needed to look at more than just fluency if we were to determine "functional outcomes." To my way of thinking, improved fluency as a desired outcome of treatment is a foregone conclusion. It seems that there is no question that the "most desired" outcome of therapy is fluent speech. Ideally, this speech is "normally fluent" in the sense that the speaker can talk whenever and wherever he or she chooses, with essentially no effort, little anxiety, in a manner that is acceptable to the speaker, and that sounds "natural" to the listener.
Ideals, unfortunately, cannot always be achieved. In my experience as a stutterer and speech-language pathologist, I have come to realize that for many stutterers "normal" fluency is an unattainable goal. This is not to suggest that I do not believe that some individuals who stutter are capable of achieving high levels of fluency, or even normal fluency. I do not believe, however, that all stutterers are capable of this. In my opinion, it was for this group of individualsthose for whom "normal" fluency is not a realistic goalthat the preponderance of the outcome statements evolved.
During (and perhaps even more following) the 1998 leadership conference, during which we attempted to take the "outcome statements" from 1997 and develop them into 7-point scale items, there arose a bit of an outcry. In the August 1998 issue of the Special Interest Division 4 newsletter, Cordes, Finn, Ingham and Packman wrote about their "reflections" on the Leadership Conference, as did Shenker, Kully, and Meltzer. Among the criticisms leveled by Cordes, et al. was the following: "If we continue our present course, though, it appears that before too long our assessment and outcomes measures for stuttering will have much more to do with convincing our clients to report that they feel generally happy about themselves and will have much less to do with assessing the occurrence or the severity of stuttering. Before too long, we will have created a system in which stutterers will still be receiving treatments that do nothing for their stuttering, but clinicians will be able to document that they are doing a great job or producing well rounded human beings who have moved from 4 to 6 on an outcome scale, and who now talk whenever they feel like it." (p. 8) Shenker, et al. said: "Although measures of satisfaction may provide important information, they do not tell us whether the client actually improved. it concerns us that in our meeting in Florida, many seemed to have lost sight of the fact that as speech-language pathologists, our first responsibility to the client should be the rapid reduction in stuttered disfluencies . While we wholeheartedly agree that successful therapy must integrate aspects of cognitive and affective change, we feel that, given the choice, most stutterers initially come to therapy to reduce stuttering behaviors. If we hold the view that treatments should be client-focused and address the primary source of complaint, then objective measures of stuttering behavior [emphasis added] must occupy a central role in outcomes measurement." (p. 10)
It might be useful to review some of the outcome statements that came out of the 1997 Leadership Conference, since these are the statements upon which the 7-point scales were to be based. The selected statements below come from the report on the 1997 conference (Bernstein Ratner and Quesal, 1998). I have chosen to review the outcomes that were intended to present the clinicians point of view and the clients point of view. (A full copy of the outcome statements is available on request.)
Preferred clinical outcomes: The preferred treatment outcome relative to the clinician is that the client will demonstrate feelings, behaviors, and thinking that lead to improved communicative performance and satisfaction with the therapy process.
These outcomes can be operationally defined to include the following:
Preferred client outcomes: As a result of therapy, the client should be able to positively rate the following outcomes:
(These outcome statements presume an adult client. Though time did not permit formal discussion, it was recognized that outcomes for therapy provided to children would have to be adjusted to reflect their particular concerns, and those of their parents).
It is difficult for me to see why these types of outcome statements are so troublesome. In my opinion, they address the realities of stuttering and stuttering therapy. In my experience, many individuals are unable to achieve "normal" levels of fluency, and many are unable to do so "rapidly." The fluency Im talking about here is day-to-day fluency, not a flight into fluency experienced by choral reading, talking with the beat of a metronome, talking under DAF, or using some sort of exaggerated way of talking. If an individual does not achieve high levels of fluency during treatment, has the client or his clinician failed? Is fluency the only measure of success in treatment? I certainly hope not.
The fluency that is "natural" for a particular speaker is based upon many factors. A person has basic speech motor skills and linguistic skills, and these combine with experiences, skills learned in therapy (or, in some cases artifacts of previous therapy), "coping behaviors" that have been developed over a long period of time, self-perceptions and many other factors that make each person unique. To suggest that all stutterers are capable of normally fluent speech is an insult to those of us who have worked for years to be effective communicators, but who still are not highly fluent speakers. It is interesting, too, that in most cases people who hold the goal of normal fluency (or high levels of fluency) as the goal for stuttering therapy tend to be individuals who do not stutter. I suppose it should not be surprising that the average person on the street feels that all stutterers should be able to talk fluently if "they just tried hard enough." Its a bit more troubling when this attitude seems to be held by some of my professional colleagues who are experts in stuttering. Its even more troubling when this attitude is expressed, implicitly or explicitly, to individuals who stutter.
Let me reemphasize here that I am not saying that we should enter the therapeutic relationship with the attitude that an individual who stutters is incapable of fluent speech and therefore we do not address speech fluency. I am suggesting that while we address fluency, there are many other factors to consider.
How do I define "success?"
I submit that stuttering therapy can be deemed "successful" if it leads to the following:
Am I taking the easy way out here? I dont believe so. I feel that these less tangible aspects of stuttering are what make it such a complex, challenging disorder both for people who stutter and for the professionals who treat stutterers. We cannot say that therapy is successful only if a client is fluent following that therapy. I feel that Special Interest Division 4 should be given credit for viewing stuttering and therapy outcomes in this broader way. I do not think anyone is giving up on fluency as a goal. However, we can help people who stutter in many, many other ways. "Successful" treatment addresses the totality of stuttering. Our outcome measures should do the same.
Cordes, A., Finn, P., Ingham, R., and Packman, A. (1998). Reflections on the 1998 Division 4 Meeting. American Speech-Language-Hearing Association Special Interest Division 4, Fluency & Fluency Disorders newsletter, 8 (3), 7-9.
Ratner, N. B., and Quesal, B. (1998). Report on the 1997 Leadership Conference in Tucson. American Speech-Language-Hearing Association Special Interest Division 4, Fluency & Fluency Disorders newsletter, 8 (1), 6-7.
Shenker, R.C., Kully, D., and Meltzer, A. (1998). Letter to the Editor Concerning the Leadership Conference. American Speech-Language-Hearing Association Special Interest Division 4, Fluency & Fluency Disorders newsletter, 8 (3), 9-10.
(This paper was based, in part, on a presentation by my former student and current professional colleague Annette Teslik and me at the 1998 Illinois Speech-Language-Hearing Association Convention, entitled "Successful" stuttering therapy: An in-depth case study." Thanks to Annette for her input on this paper.)