The first thing I should make clear at the outset of this paper, is that, despite having taken a graduate course in fluency, and many years of experience as a speech-language pathologist, it is not so very long ago that I felt a significant amount of discomfort in working with fluency clients. I attributed this to my relative lack of exposure to clients who stuttered, compared to other disorder types, as well as the training I received. I did have a course devoted to fluency disorders at the graduate level. However, simply reading and hearing lectures about theories of the onset and development of stuttering and reviewing therapeutic techniques was somehow not sufficient to make me feel confident in serving clients who came to me with fluency disorders, even when I experienced success in working with these clients.
Somewhere on the order of 12 years ago, I was assigned to teach the undergraduate course in fluency disorders at the college where I work. A few years later, I was asked to teach the graduate course in fluency disorders, passing the undergraduate course on to someone else. Although I had worked with a number of clients who stuttered by that time, I did not feel particularly adept at fluency therapy, nor would I have considered myself in any way an expert in that area. With much reading, preparation and consultation with others more experienced in fluency disorders, I began to learn more about stuttering and its treatment, and discovered an increase in my confidence as a clinician working with stuttering. Early on in my teaching on the topic of fluency disorders, I became concerned that my students showed a high degree of discomfort with the area of stuttering, often expressing the same fears and concerns I had felt as a student and, later, as a clinician. I began asking students about their comfort level in working with stuttering at the start and finish of the course, and discovered that they reported no more confidence in their ability to work with stuttering at the end of the class than they had at its beginning.
A survey of the literature on speech-language pathologists and stuttering demonstrates that this is a fairly widespread problem. For example, St. Louis and Durrenberger (1993) report that professional clinicians show a low preference for treating fluency clients. Sommers and Caruso (1995) surveyed training program directors and clinical supervisors, identifying a paucity of training at both the pre-service and in-service levels. Kelly et al. (1997), who surveyed school speech-language pathologists in 157 Indiana schools, also support this finding. 50% of the school clinicians surveyed reported having inadequate training for working with stuttering clients. My own experience as a graduate student seems to match that of my students and, according to reports in the literature, many other students and practicing clinicians. Many of us are hesitant, if not downright afraid, of working with people who stutter.
It became clear to me that one way to possibly begin to remedy this situation was to change the way I was teaching my fluency course. I began trying a variety of changes each time I taught the course, with the idea of desensitizing students to working with stuttering clients, much as I have worked with clients to help desensitize them to their own stuttering. I have modified the graduate fluency course in several ways to move toward this goal: increasing the breadth of coverage of intervention methods, increasing the connection between theory and practice, increasing student exposure to people who stutter, and increasing their exposure to the experience of changing behavior relative to fluency. It is important for me to say here that I am grateful to many superb instructors, clinicians, and clients for their ideas, which I have borrowed in great numbers over the years to facilitate this desensitization process. I cannot name all of these individuals here, as the list would be too long, but I appreciate the ideas and the wisdom that I have gained from them.
Before reviewing some of the changes I have made to the graduate course over the years, I will briefly review the course content, so that you will have some idea of the types of information covered in the class. The students in the class generally divide into two groups, those who have had an undergraduate course in fluency and those who have not. Although students who receive their bachelor's degree from our institution take an introductory fluency course at the undergraduate level, many of the students coming from other institutions into our graduate program have not had such a course. So, I generally begin with a three week overview, which is intended to introduce terms related to fluency disorders and to present the basic elements of stuttering theory regarding the onset and development of the disorder. Students not having a previous background in fluency disorders are encouraged to do some outside reading on the topic. The next three weeks are devoted primarily to the assessment of fluency disorders, and the remaining nine weeks focus on treatment. I cover fluency shaping and stuttering modification treatment, as well as the integration of techniques taken from both of these treatment types. Counseling clients and their families is included in this discussion of treatment.
One of the first changes I made to my graduate course was that of having the students talk about their feelings regarding working with stuttering clients. I generally discuss student fears and concerns on the first day of class. I also share with them some of my own experiences, so that they can see that their discomfort is not entirely unique to them. Students tend to have the notion that their instructors know everything about a subject, and that they probably started out being exceptional clinicians from the first day on the job. They may have unrealistic expectations for themselves, as a result. I think it is important for them to realize that learning is a process whereby we all begin by feeling less-than-competent, and continue to increase our knowledge and hone our skills across our professional lives. The discussion during the first class may also include talking about students' previous exposure to people who stutter, and their perceptions of the people they have met. Sometimes I have students turn in anonymous written responses to the questions, "What do you hope to gain from this class?" and "How do you feel about working with fluency clients?", particularly when the group is not very talkative during the first class meeting. Often, students who are not comfortable speaking out in class will share their feelings in an anonymous note to me.
Exposure to people of varying ages and types of disfluencies has become a more important component of our fluency class. I generally try to invite one or two adults who stutter to visit with the class, sharing their own experiences and fielding questions from the class. I am most grateful to the people who have kindly volunteered their time to speak with my class, and my students have invariably come up with some wonderful questions and comments for the speaker(s). One class period devoted to meeting one or two people who stutter is a small amount of exposure, so I began to search for other ways to get students to meet people who stutter. We are fortunate in having a speech-language pathologist in our community who specializes in fluency treatment. She has weekly group meetings for her clients, and they welcome students in small numbers to attend their meetings. I encourage my students to go to at least one of these meetings during the semester, if possible, to expand their exposure to stuttering and the variety of people who experience the disorder and its treatment. This year, for the first time, I am requiring students in the class to read Marty Jezer's thoughtful and well-written autobiography, "Stuttering: A Life Bound Up in Words". This is yet another avenue through which they can meet someone who stutters in a more in-depth way, responding to me in writing about what they find within the pages of this book.
In addition to a face-to-face meeting with people who stutter, and reading about one person's experiences, I incorporate numerous videotaped samples of children, teens, and adults who stutter across the course of the semester. We have videotaped samples from people who have attended therapy at our on-campus clinic over the years, all of whom signed a release form, allowing us to videotape their sessions for use in our classes. There are also numerous excellent videotapes available from the National Stuttering Association and the Stuttering Foundation of America. These allow students to understand the variety of types of disfluencies, and also provide them with the opportunity to learn how to carry out some of the various measures of fluency that are a part of fluency assessment at the onset of treatment and at points along the way. I have increased the use of videotapes in the past few years, since student feedback has supported my view that they gain a better grasp of assessment and treatment methods when they are able to see them being demonstrated.
I have recently begun to incorporate case studies into the graduate course as a way of connecting theory and book-knowledge of treatment techniques with practical applications. Some of these cases are clients who have been or who are currently being seen in our on-campus clinic, while others are taken from a variety of texts on fluency disorders and treatment. In the case where current clients are being discussed, students are provided with the schedule for fluency clients who are attending our on-campus clinic, so that they may observe fluency treatment sessions. Clients and their families are made aware that students may observe their sessions. This observation is done via remote television monitors, so clients are not disturbed by commotion outside of the clinic room. I am most appreciative of the willingness of our clients and families to have sessions observed, as this provides an excellent source of practical application training for students. The use of videotaped therapy is a good option, especially when fluency clients are not readily available. Last year, I used a series of videotaped sessions entitled, "Therapy in Action", by Charles van Riper (published by the Stuttering Foundation of America) to help students understand how Van Riper's therapy "looks" in action. Many of you may know this individual as the grandfather of stuttering modification therapy. There are several excellent written descriptions of the therapy techniques that he developed. In my experience, it is difficult for students to make the transition from reading about all of those stages and techniques to making use of them in treatment. We watch segments of these videotapes (there are nine tapes in the series) and practice some of the techniques that van Riper asks the client, Jeff, to use. I also have discussions in class about what the students see as useful, how Jeff is reacting, what modifications van Riper suggests when Jeff is uncomfortable with a therapy assignment, what they might do next, were they Jeff's clinician, and so forth.
In my experience with teaching this course, the use of guest speakers who stutter, observation of samples of disfluent speakers, and case studies all enhance the students' understanding of and comfort level with fluency disorders and their treatment. There are several other assignments/content that I have incorporated into the class in order to make stuttering more personal for the students, and to help them gain some understanding of what it is that we ask our clients to do when they are involved in treatment. The first of these is a pseudostuttering assignment. It is probably one of the least favorite of the assignments for the class among the students, although, by their own reports following completion of the assignment, it often is one of the more valuable ones. Over a period of five weeks, the students work to learn how to pseudostutter (imitate stuttering behavior) with the help of a partner. At first, they are asked to practice imitating prolongations, repetitions, blocks, and so forth, on single words and in short sentences. Later, they begin to add struggle behaviors, although some report that these come naturally, as they continue to work on learning the core behaviors of stuttering. Toward the end of the assignment, they make some phone calls to order pizza or ask directions using their pseudostuttering, and finally, they must arrange several appearances in public places, using their pseudostuttering while making inquiries of strangers. Students maintain a journal throughout the assignment, reporting their feelings prior to, during and after the assignment. This is turned in to me at the end of the five-week period.
I give this assignment with several goals in mind. One of these is simply to help them learn how to mimic stuttering behavior in preparation for working with clients. This can assist the clinician in understanding the stuttering behavior of a client, and in some cases, assist the client in understanding the specific behaviors that they are exhibiting when they stutter. Another goal is to help the students understand what is involved in making changes in one's speech. As speech pathologists, they will be asking fluency clients to make significant and sometimes quite difficult changes in their speech. I want them to experience something of the discomfort and physical difficulties that accompany making such changes, albeit in the reverse direction and in much smaller measure than is experienced by someone who really stutters. Finally, I want them to at least have a small degree of understanding of what it is to go out in public and have to stutter. True, the students can, and often do, chicken out and revert to their normally fluent speaking patterns. Even when they do this, they report the stomach-churning anticipation of stuttering, and most find it an eye-opening experience. There are often several students who feel that the assignment is unethical, since they are, in essence, lying by pretending to be what they are not. Some also report that they feel that they are mocking stuttering by doing the assignment. While their viewpoints do have merit, I continue to give this assignment. When it is done with the intention of learning to understand and respect people who stutter, and gaining some grasp of what it is that we ask fluency clients to do in treatment, then I believe that it has value.
In addition to the pseudostuttering assignment, I ask students to join an on-line discussion of fluency disorders. E-mail accounts are available to our students and computers are available on-campus for those who do not have Internet access at home. Students are assigned to subscribe to Stutt-L, a listserv that is intended for those who stutter as well as professionals in the field of fluency disorders. The students are to "lurk" on Stutt-L, meaning that they read the threaded discussions without being required to respond or comment on any of them. This assignment is evaluated by having students send me a commentary on at least four threads that they follow across the duration of the semester. I have had some very good e-mail or in-person discussions with individual students and with the entire class as a result of this assignment. The primary benefit I have observed is that students begin to see that people who stutter are very different individuals. The fact that they stutter does not make them all behave in the same manner or have the same opinions about any particular topic, from treatment preferences to what type of jokes they like to tell. In other words, it breaks down the stereotypes that are so easily formed when one considers a group of people who share some trait without knowing many of those individuals. The students also have the opportunity to hear from other professionals about fluency disorders. I like to expose them to opinions that may differ from mine, and to get them thinking about the many sides that exit to almost any issue that turns up on Stutt-L.
A third example of content that I have added to the course is to familiarize students with some of the fine resources that are available to them for clinician and client education and support. I ask them to go to the websites for the National Stuttering Association and the Stuttering Foundation of America, where they will find a wealth of reading materials for themselves and their clients. I make sure to show portions of some of the videotapes available through these groups, and explain the ways that I have used them as a part of treatment. I read them portions of some of my favorite books, particularly books or pamphlets that clients will enjoy. I give them web addresses for other support groups for stuttering, such as Friends, which is designed as a support group for children who stutter and their families, and Passing Twice, which supports gay, lesbian and bisexual people who stutter. Judy Kuster's Stuttering Homepage, where each of you probably accessed this online conference, is a wonderful source for both clinicians and people who stutter. I try to show them what is available through this source, and share some of the ways that I have used it in clinic with fluency clients. For example, I love taking kids there and having them read stories written by other kids who stutter. One little boy submitted his own story after reading others, and was tickled to see his right up there on the computer. Students should not have to find all of these gems by themselves. Although time is short in any semester-long course, I think it is important for them to have a head start in gathering a variety of different resources that will allow them to shape treatment to fit their clients' interests and needs.
I see that I am getting to the end of my allotted space, so let me close by saying that I consider this course to be a work in progress. I have had positive feedback from former students, who are now working as professionals. I have also been fortunate to work with some of the students who have taken the course, supervising them with fluency clients. I am seeing student clinicians who are better prepared to work with stuttering, who are excited to be working with children and adults who stutter, and who report that they feel comfortable in doing so. That is an absolute delight for me as an instructor and a supervisor. There are many ideas that I would like to try in the future. For example, McKeehan (1994) reports that graduate students responded positively to their own practice in using fluency-facilitating techniques, both in class and in outside speaking situations. I would like to incorporate this in a more systematic way into my class. Coming up with beneficial ways to have students practice the counseling techniques that we discuss is also an area where I want to make some improvements. The more I work on this course, the more I become convinced that it should span two semesters rather than one. This is another goal that I have on my list of things-to-discuss in our department faculty meetings.
It is with great anticipation that I await responses from those of you who read this paper. I warn you that I have every intention of picking your brains for new ideas that will help me further improve the quality of this course. Thank you for taking the time to share your thoughts and ideas with me.
Kelly, E.M., Martin, J.S., Baker, K.E., Rivera, N.I., Bishop, J.E., Krizizke, C.B., Stettler, D.S., & Stealy, J.M. (1997). Academic and clinical preparation and practices of school speech-language pathologists with people who stutter. LSHSS, 28, 195-212.
McKeehan, A.B. (1994). Student experiences with fluency facilitating speech strategies. Journal of Fluency Disorders, 19, 113-123.
Sommers, R.K., & Caruso, A.J. (1995). Inservice training in speech-language pathology: Are we meeting the needs for fluency training? AJSLP, 4, 22-28.
St. Louis, K.O., & Durrenberger, C.H. (1993, December). What communication disorders do experienced clinicians prefer to manage? ASHA, 23-31.