About the presenter: Rodney Gabel, Ph.D., CCC-SLP, BRS-FD, is a licensed and certified speech-language pathologist and an Associate Professor at Bowling Green State University. Dr.Gabel earned his BS and MS from Bowling Green State University, and his Ph.D. from the Pennsylvania State University. Dr. Gabel teaches courses in stuttering, guides students' research, and directs BGSU's Intensive Stuttering Clinic for Adolescents and Adults. He actively conducts research and has published research articles, all dealing with stuttering. Rod is active in consulting and presenting seminars/workshops in Ohio and around the country.

You can post Questions/comments about the following paper to the author before October 22, 2008.

Multifaceted Stuttering Therapy for Adolescents and Adults: Intensive Therapy and Telepractice

by Rod Gabel
from Ohio, USA

Now more than ever, it is imperative that there be accessible and appropriate stuttering therapy for adults and adolescents who stutter. For many people who stutter (PWS), appropriate therapy is difficult to access for several reasons. One such reason is that many speech-language pathologists (SLPs) report being uncomfortable or ill-prepared to work with PWS (Brisk, Healey, & Hux, 1997; St. Louis & Durrenberger, 1993). This lack of comfort and preparation may be due to a continuing reduction in educational and clinical experiences related to stuttering (Yaruss & Quesal, 2002). Moreover, there continue to be few SLPs who specialize in treating individuals who stutter (Manning, 2001). These issues, along with the difficult nature of stuttering and the length of therapy, make identifying appropriate treatment very difficult.

One way to provide treatment to adults and adolescents who stutter is through intensive therapy programs (Boberg & Kully, 1994; Kully, Langevin, & Lomheim, 2007; O'Brian, Packman, & Onslowe, 2008). Intensive programs allow individuals to live in close proximity to a clinic, which usually employs specialists in stuttering, for a short period of time (i.e. generally three weeks or fewer). This type of treatment allows individuals to have a very positive therapy experience that is unavailable in the city or area in which they live. Many intensive programs report positive outcomes (Boberg & Kully, 1994; Kully, et. al, 2007; O'Brian, et. al, 2008).

To address the issue of access, my students (Farzan Irani, Scott Palasik, Eric Swarts, Charlie Hughes) at Bowling Green State University and I have continued to offer the Intensive Stuttering Clinic for Adolescents and Adults. During the past year, the program has undergone changes in philosophy that reflect our commitment to offering follow-up services. Thus, the program is now called the Multifaceted Stuttering Program for Adolescents and Adults. Over the past seven years, the intensive portion of the clinic has been offered on five occasions. In all, 24 individuals between the ages of 12 and 39 have participated. Though there have been subtle differences in the schedule and approaches utilized, each offering has included between 75 and 80 hours of direct treatment over a 15-day period. We are constantly in the process of using evidence-based practice (EBP) to help guide appropriate changes to our therapy and to the structure of the clinic.

The clinic employs a multifaceted therapy program, which includes speech restructuring (i.e., fluency shaping), stuttering modification, and counseling (i.e., self-help) approaches. The program was initially developed based on therapy models described by several authors (Gregory, 2003; Guitar, 2006). Prior to initiating therapy, each client is engaged in a diagnostic. During this assessment, several speech samples are gathered in both clinical (reading, monologues, and conversations) and extra-clinical contexts (conversations and phone calls). The clinicians complete standard measurements of speech fluency (i.e., syllables stuttered), speech naturalness, and stuttering severity. Additionally, pencil-and-paper questionnaires such as the Erickson S-24 (Andrews & Cutler, 1974), the Locus of Control of Behavior (LCB) (Craig, Franklin, & Andrews, 1984) and The Speech Locus of Control (SP-LOC) (McDonough & Quesal, 1988) are used to assess the clients' affective and cognitive reactions to stuttering and readiness for change. Each clinical measure is completed during the start of the intensive program, again at the end of the program, and during any follow-up therapy.

During the assessment, we also attempt to analyze the clients' values and perspectives related to treatment, in an attempt to incorporate all three aspects of EBP into delivering and measuring our program. To do this, each client is engaged in a semi-structured interview. During the interview, the clients are engaged in a discussion of how stuttering has affected their lives, the experiences they have had with stuttering, and their expectations and goals for therapy. Each client's narrative from this interview is assessed using qualitative procedures (Patton, 2002) and used as a benchmark for tailoring the therapy program to meet his or her needs. At the end of the program, the interview is repeated, but the clients are asked to reflect on their experience in therapy. This narrative is also analyzed and then compared to the initial narrative. We believe that the information from these interviews is very important and, in some ways, might be more important than the clinical measurements in understanding the benefits of our program.

Structure of the Multifaceted Stuttering Program for Adolescents and Adults

The therapy program is delivered in three phases. Phase I of the program is generally initiated on the first day of therapy. During this phase, the clients are engaged in a process of increasing their awareness and understanding of stuttering. During both individual and group sessions, the clinicians guide the clients in identifying the behaviors that make up their stuttering problem: types of disfluencies, secondary physical reactions and tension, negative emotional reactions, and negative communication attitudes (Van Riper, 1982). During Phase 2 of the program, initiated during the first three to four days of therapy, the clients learn ways in which they might reduce the tension in their speech and stuttering. Open and honest stuttering, as well as pseudo stuttering are utilized to assist clients in learning new ways to stutter without tension (Van Riper, 1982). In the later stages of Phase II, which generally spans the entire program, the clients practice modification skills such as pull-outs and cancellations (Van Riper, 1982). During the third phase of therapy, clients learn speech restructuring techniques. Specifically, clients learn behaviors such as easy onsets, deliberate phonation, airflow management, and reduced rate. The clients learn to use each technique at a very slow speech rate, and then these new behaviors are generalized in the clinic at increasing speech rates, and finally at more normal speech rates in extra-clinical settings. This phase of treatment begins early in the second week of therapy and is a focus until the end of therapy.

Throughout the clinic, the clients are engaged in discussions that direct them to develop an individual maintenance program, which often includes a suggestion for follow-up therapy. In fact, clients are offered a variety of options for follow-up therapy. First, they can attend weekly or bi-weekly sessions at the Bowling Green Speech and Hearing Clinic or off-site at their school. To date, only four of the 24 clients have utilized this model. This is due to the majority of clients attending the intensive clinic having been from outside the Bowling Green and Northwest Ohio area. In addition, six of the 24 clients have attended 10-hour intensive follow-up sessions offered 3 times a year. Due to the low critical mass attending these follow-up clinics, only one client per session on average, we can no longer offer this option. Also, three clients have used weekly phone sessions to guide their follow-up therapy. The phone sessions were essentially a primitive form of telepractice, and had some limited success despite the obvious impracticality of the approach.

Outcomes, Weaknesses, and Future Directions for this Program

Though most of our data for the program is unpublished, we can safely say that both clinical data and client reports suggest the intensive phase of the program has been beneficial. More specifically, the reduction in severity and attitude change has been more dramatic than changes in speech fluency (Gabel, 2006; Gabel, Daniels, & Hughes, 2005; 2008). Similarly, feedback from the clients, both during semi-structured interviews and from quality assurance questionnaires suggests that the therapy program is important, and perhaps a "life-changing" experience. Efforts have begun to report small outcome studies for different groups who have attended the program. These reports suggest the multiple benefits of the program (Daniels, 2004; Gabel, et.al, 2005; 2008). The long-term benefits of the program are being explored using archival data from the clinic, follow-up questionnaires, and outcome studies.

This clinic, like many other intensive programs (for example Kully, et. al, 2007), operates as a clinical training program for student clinicians and specialists. Thus far, 34 masters students and six doctoral students have completed this experience. These students have reported that the program has been a very positive experience. Though preliminary, it appears that all of the students report that they feel prepared and comfortable working with PWS as a result of this clinical experience.

One of the primary weaknesses identified in offering this program is the lack of structure to the follow-up component of therapy. We simply have not had enough opportunities to monitor and provide support to our clients directly on a consistent basis following the intensive portion of therapy. We believe this contact is critical for the clients to have any long term success. Additionally, it has been nearly impossible to measure the long-term benefits and feasibility of our program without this type of contact. This past summer, we initiated a telepractice therapy using computerized, video chat technology (Logitech QuickCam and SKYPE) for the five clients who attended the intensive clinic. Similar approaches have been reported by other intensive programs (Kully, et. al, 2007; O'Brian et. Al, 2008). Though it is too early to assess fully the benefits of our telepractice services, our initial data suggest that all of the clients were able to access the service, completed weekly or bi-weekly therapy sessions, and continued to maintain and progress in their therapy. As an added benefit, the use of the telepractice model allows us to gather the necessary data to report the long-term outcomes of treatment.

Another major problem is that our data suggest that the intensive program remains inaccessible to many individuals. Each year, between 15 and 20 individuals have inquired and requested application information for attending the intensive program. Fewer than half of these individuals have been able to attend each year. It appears that the difficulties relate to the financial burden of relocating to Bowling Green, as well as the time away from work and school during the three week program. Other intensive programs report similar difficulties, and have suggested avenues for reducing the length of these program, without compromising the therapy (Kully, et. al, 2007; O'Brian, et al., 2008). In this vein, we will be offering the intensive portion of the Multifaceted Therapy Program for Adolescents and Adults, over two nine day sessions in July of 2009. The program will still include 75 hours of therapy and incorporate all of the approaches and goals of the earlier three-week program. In essence, the shorter period will both reduce the financial costs (i.e., room and board) related to attending the program and allow clients to take less time away from work and other activities. We expect that these changes, along with the telepractice portion of the program, will allow more individuals to access this program.

Journal of Speech & Hearing Disorders, 39, 312-319.

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Brisk, D.J., Healey, E.C., & Hux, K.A. (1997). Clinicians' training and confidence associated with treating school-age children who stutter: A national survey. Language, Speech, and Hearing Services in Schools, 28, 164-176.

Craig, A. R., Franklin, J. A., & Andrews, G. (1984). A scale to measure locus of control of behaviour. British Journal of Medical Psychology, 57, 173-180.

Gabel, R., Daniels, D., & Hughes, S. (2005). BGSU's intensive stuttering clinic for adolescents and adults. Annual Convention of the National Stuttering Association. Chicago, Illinois.

Gabel, R., Daniels, D., & Hughes, S. (2008). A Mixed-model Approach to Studying Treatment Outcomes. Perspectives on Fluency and Fluency Disorders, 18, 6-16.

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Yaruss, J.S., & Quesal, R. (2002). Academic and clinical education in fluency disorders: An update. Journal of Fluency Disorders, 27, 43-63.

You can post Questions/comments about the above paper to the author before October 22, 2008.

SUBMITTED September 15, 2008
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