|About the presenter: Joseph Donaher, Ph.D., CCC-SLP, is the Coordinator of the Stuttering Program at the Children's Hospital of Philadelphia. He is a Board Recognized Specialist and adjunct instructor at Temple University. His clinical and research interests focus on the assessment and treatment of stuttering and disfluency patterns secondary to neurological conditions such as Tourette Syndrome and ADHD. Joe lives outside of Philadelphia with his wife and two children.|
|About the presenter: Joe Klein is a person who stutters and an assistant professor in Communication Sciences and Disorders at The College of St. Rose in Albany, NY. Joe supervises therapy for people who stutter and teaches classes in fluency disorders. Joe has presented nationally at the American Speech-Language-Hearing Association, Friends: The Association of Young People who Stutter, and The National Stuttering Association conventions. He has also published articles in Contemporary Issues in Communication Sciences and Disorders, The Journal of Fluency Disorders, and The Journal of Stuttering Therapy, Advocacy, and Research. Joe lives in Albany, NY with his wife, Holly, and two children, Zachary and Greta.|
Several months back, Judy Kuster approached the authors and suggested that they co-write an article on whether a speech therapist must stutter to be effective working with people who stutter. She thought that it would be an interesting article since one author stutters and one does not. It would also be intriguing given that the authors grew up within 30 minutes of each other, are approximately the same age, are both married with 2 children, and are both named Joe (Apparently Joe Kalinowski did not return Judy's call). Below you will see how Joe and Joe answered Judy's original question.
JOE KLEIN'S SECTION
Being a stutterer and a speech therapist helps me in my work with people who stutter because, well, I stutter. I have a long history with stuttering, a personal understanding that stuttering is much more than just a speech problem, and even a personal understanding that stuttering is not always a problem, sometimes just a difference, but sometimes difficult, frustrating, or even handicapping. As such, when a client or any person who stutters tells a story about their stuttering, I can often say, "Ah yes, been there, done that." At times, this can be very comforting to the person. Our therapeutic relationship can grow as I am able to share something clinically relevant about myself, which is a good model for the client. I certainly hope that she will share information about herself and her stuttering with me and begin to share that same information with those close to her.
However, this is also a negative of one stutterer working with another. The fact that I have experienced a similar situation may be, in reality, of little use to the person sitting across from me. In fact, this kind of interaction can be detrimental. If a client starts discussing her stuttering, and I chime in with, "yes, one time, what happened to me was..." I am no longer working with my client. I am talking about me, having really good therapy for myself as my client, now my therapist, actively listens to my story.
There is much that we still do not understand about stuttering, but one thing that we do know is that stuttering is tremendously variable (Starkweather & Givens-Ackerman, 1997). Not only will another person's stuttering be very different from my stuttering, but her cognitive and emotional reactions to that stuttering will be different from mine. Not to mention that her goals may be different from mine, as well. While working with a teenager recently, one of her goals was to be able to read more fluently in class. It was not long before she was able to read a paragraph fluently.
"What do you think?" I asked, "Is this something you would be able to try in class?" Of course she would say yes, she sounded wonderful.
Her answer was NO. "I sound weird, like a teacher," she said.
I had taught her to try to read like me, to be fluent like me, and not like her. Just because I "get" my stuttering, does not mean that I "get" others' stuttering. Hmmmm... perhaps good fluency and/or stuttering therapy has little to with fluency and stuttering, for both the client and the clinician. But what, then, does good stuttering therapy involve? Zebrowski (2008), using estimates from Asay and Lambert (2004), suggests that only 15% of change in any therapy may be due to technique. The big chunk of change appears to come from the client and her environment (40%) and from the therapeutic relationship (30%). The remaining 15% comes from hope and expectancy. To me, that means that the clinician can impact a great deal of the therapeutic outcome, and the biggest impact clinicians can have may be due to the therapeutic relationship itself.
The therapeutic relationship, at its core, involves the client and the clinician working collaboratively and purposefully (Baldwin, Wampold, and Imel, 2007). Interestingly, Baldwin, Wampold and Imel found that the clinician is ultimately responsible for this relationship, and hypothesize that clinicians who are able to instill hope, provide meaningful explanations of the problem, and provide individual treatments consistent with that problem are going to be the most effective at forming a helpful alliance with their client.
So, does fluency have anything to do with being a good therapist for someone who stutters? Our best guess is probably not. In order to fully use that 15% of technique, both fluent and stuttering therapists will have to be able to model normal fluency and stuttering, perhaps in a number of different ways. The stuttering therapist, therefore, may need to be able to model some fluency facilitating behaviors, and the fluent therapist may need to be able to model some hard and easy stuttering, depending on what the needs of the client are in any particular therapy session. The most important factors leading to change in people who stutter probably has very little to do with the speech or past history of the clinician, and much to do with the work and problem solving done in and out of the therapy session.
JOE DONAHER'S SECTION
In order to answer the question of whether a speech therapist needs to stutter to be effective working with people who stutter, a more basic question needs to be answered. This question relates to the role of the therapist in the therapeutic relationship. Once this topic has been discussed, it will be simpler to determine whether stuttering affects a clinician's ability to assume that role. However, it should come as no surprise to the reader that the conclusion of this paper will suggest that stuttering is not a mandatory characteristic for working with people who stutter. If it were, at least one of the Joes would be out of a job!
Many writers have suggested that the role of a therapist is similar to the role of a coach. In previous ISAD conferences, both Walt Manning and John Tetnowski have drawn parallels between their experiences coaching soccer and their experiences working with people who stutter. Interestingly, both writers have discussed how the basic principles of sports psychology were applicable in speech therapy. Perhaps it is because I coached my daughter's soccer team to an undefeated season last year (non-goal oriented soccer team where you do not keep score!) but their ideas have helped to clarify my thinking of what it takes to be a good clinician.
A good clinician knows how to listen to the client in an effort to learn more about how stuttering impacts all aspects of the individual's life. They demonstrate empathy or the ability to relate to the emotions that an individual is expressing without having to experience the exact situation. This may be easier when a clinician has first hand experience with similar emotions, albeit for different reasons and in different situations. However, clinicians should be weary of assuming that they know how any given client feels or thinks. For a clinician who does not stutter, this may surface as assuming that since they have experienced similar feelings, they know what it is like to stutter. For the clinician who stutters, this may surface as assuming that their feelings and thoughts related to their own stuttering are universal truths for all people who stutter.
Another role played by a good clinician is that of a facilitator who creates a nurturing and safe clinical environment where the client and clinician can openly share experiences, make observations, propose alternative actions and/or practice newly acquired skills. This fosters the belief that setting goals, charting progress and making adjustments to the plan is a joint venture between all parties. This results when clinicians demonstrate through their words and actions that they are committed to working with the client, that they are knowledgeable about stuttering and that all parties are equals in the process. Starkweather and Givens-Ackerman (1997) labeled this Therapy as a Conversation and described it as an "ongoing exchange of ideas, thoughts, feelings and perspectives between people."
Obviously all clinicians should support their clients by educating them on stuttering, advocating for them and providing realistic feedback in a constructive way. However, clinicians must also challenge their clients. This includes challenging their belief systems regarding stuttering, challenging their typical actions and coping mechanisms and challenging their willingness to take risks or to try something different. Great clinicians empower their clients to objectively evaluate their performance through increased self-awareness and self-monitoring abilities. In this way, the client begins to "become their own therapist" and learns to make adjustments and work through issues on their own.
As discussed earlier, the role of a clinician is much like the role of a coach. A good coach must assess his team's strengths and weaknesses, teach specific skills, motivate, advocate for and listen to his players. He needs to encourage them to make productive decisions during the game and assist with making adjustments to the plan as needed. Similarly, a good clinician knows how to listen empathetically, facilitate open sharing, educate, advocate for, motivate, support and challenge their clients. While these skills rarely come naturally and typically take time to develop, they do not necessitate that the clinician be a person who stutters.
The authors feel that one more question needs to be answered before concluding. That question is: Why do people keep asking whether it matters if a clinician stutters or not? The answer, as postulated by the Joes, relates more to the person asking the question than to the person being asked. When people feel threatened or when they can not handle a topic that has been raised, they naturally seek to discount the message or to diminish the person raising the issue.
As an example, imagine a situation which occurred several years back when one of the authors was supervising a graduate student clinician who stutters. While working with a young boy who stutters, the graduate student stuttered on several words. The boy's father then loudly asked, "if you can't fix your own stuttering, why are you working with my son?" This father was not being driven by malice but from a genuine fear of stuttering. This question has additionally been raised by people who stutter in an attempt to diminish the skills of speech therapists. Imagine a therapist who is challenging a client to take a risk or to discuss something that is highly sensitive. The client then shoots back with "you just don't understand since you do not stutter." Again, the individual was not actively trying to insult the clinician but was looking for a way to deflect the challenge.
When confronted in this fashion, the therapist has two options. The first is to react to the resistance by arguing with the person who made the comment. In the first situation, for the clinician who stutters, this would sound something like "just because I stutter does not mean that I can't be a great therapist." In the second situation, for the clinician who does not stutter, this might sound like, "I work with many people who stutter and I know about stuttering." Either way, it diminishes the therapeutic relationship and does not serve a productive purpose.
A second option would be to objectively comment on the question. For example, the clinician who stutters may have said, "from that question, it sounds like you are really worried about your son?" In the second example, the clinician who does not stutter, might have commented, "it feels like this assignment is very hard for you?" This addresses the underlying motivation while not allowing the individual to change the topic or skirt the issue.
This paper should reinforce the idea that questions are not always an attempt to gather information. A skilled clinician knows how to interpret the underling intent from the outward form. In this way, clinicians will be better able to understand and learn from their clients in an effort to move forward together.
Asay, T. P., & Lambert, M.J. (2004). The empirical case for the common factors in therapy: Quantitative findings. In M. Hubble, B. Duncan & S. Miller (Eds.), The heart and soul of change: What works in therapy (pp. 23-55). Washington DC: American Psychological Association.
Baldwin, S. A., Wampold, B. E., & Imel, Z. E. (2007). Untangling the alliance-outcome correlation: Exploring the relative importance of therapist and patient variability in the alliance. Journal of Consulting and Clinical Psychology, Vol 75(6), 842-852.
Starkweather, C. W., & Givens-Ackerman, J. (1997). Stuttering. Austin, TX: Pro-Ed.
Zebrowski, P. M. (2007). Treatment factors that influence therapy outcomes of children who stutter. In E. G. Conture & R. F. Curlee (Eds), Stuttering and Related Disorders of Fluency, 3rd Edition. New York: Thieme.
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