I would like this article to be useful not just for therapists who are working with parents, but also for parents whose children are being seen by a speech therapist, but the article is written primarily for the speech therapist. It is my hope that parents will also find it helpful. I am going to spend most of the article discussing the way that therapists talk to the parents of preschool children who stutter. Then, toward the end, I will add a few comments about talking to the parents of older children and adults.
The neophyte therapist often misunderstands the important role played by parents in the treatment of stuttering. This is nowhere more true than in the treatment of very young children at risk for, or actually, stuttering. But the parents are still important in the treatment of school aged stuttering. And, even with adult stutterers, there are issues that need to be raised with parents even many years after the fact. And often enough, the therapist is young, unmarried, never been a parent, and feels uncomfortable in the role of "giving advice" on parenting to parents.
Well, first of all, SLP's should not see their role as "giving advice". We are therapists. Our job is to enter a relationship with our clients and then use that relationship to provide healing, in our case, an easier and simpler way to talk. And, our relationship with the client includes a relationship with the client's parents. In the case of very young clients, our relationship with the parents is essential; there can be no recovery, or very little, without their participation.
On the other hand, the parent coming to see a speech therapist for the first time expects to find a solution to the child's stuttering problem, and they expect their relationship with the therapist to be characterized by respect, openness, competence, and professionalism. Professionalism, however, does not necessarily mean that the therapist will wear a white coat or any of the trappings of an authority figure. Indeed, when working with children and their parents, it is far more effective for therapists not to adopt an authoritarian air. They will show their competence by what they say and do, and should be respected for what they know. In our clinic, we are careful to have a reverse dress code. We dress casually so that neither children nor adults will feel intimidated. People who stutter are inclined to feel inferior by virtue of their disorder, and we do not want to add to that feeling. I once expressed this point of view at a professional conference, and one of the attendees replied "Poppycock! If I go to my lawyer, I don't want him to be wearing jeans!" I wish I had said then that I agreed about the lawyer, but would hate to have the same relationship with my therapist that I have with my lawyer. Everything that the therapist says or does should be designed to encourage a comfortable and open relationship with the parent, and this includes dress..
Stuttering is a problem that, in a sense, invades the family, causing reactions (some of which are very helpful, some not) in parents and siblings, which cause further reactions in the child. Just the act of bringing the child to see a therapist is a reaction to the presenting problem. As the problem manifests itself, the family dynamics change in a number of ways, some subtle and some not. The therapist then enters this dynamic process and becomes a part of it. So, in the somewhat limited area of the child's stuttering, the therapist becomes a part of the dynamic, and in this sense a part of the family. It is therefore important for the therapist to be a model of comfort, openness, casualness, and dedication to the solution of this presenting problem.
Therapists will not know everything that needs to be known, and should not take on more expertise than they can deliver, but they will be able to find answers through consultation, referral, or research.
Being a parent is a unique aspect of life. Most people remember when they first became parents as a time when their lives changed forever. We don't have many such events in life, so it is clear that something big happens at that moment -- for me, it was a relatively sudden realization that I had a new, and huge, responsibility in my life. I should add that I found it quite unpleasant at first, even depressing, like a weight had descended on my shoulders. This passed and was replaced by the many joys (and some newer anxieties) of parenthood, but I have never forgotten the moment. I am sure it is a different kind of event for each parent, but it seems, in many cases, to be life-changing. So parenting is a very important activity for most people.
Parents are, of course, protective and caring about their children. That is, they have a profound sense of responsibility for their well being. At the same time, the parents of young children often feel insecure about their ability as parents, particularly if the child in question is their first, and particularly when they are faced with a difficulty which is the first "problem" the child has had, and when the problem is something they know very little about. This sense that they are in charge but don't quite know what to do creates a distinctive tension, in which they crave help from the therapist but may resist it if it seems not to fit with their own instincts. Therapists need to respect the parents' sense of responsibility and not try to make decisions for them, but they also need to show understanding and support for their uncertainty. Some parents, because of their uncertainty, might allow the therapist to "take over", although most will not, but even when they do, it will make them feel even more incompetent and guilty that they have let someone else assume the responsibility that is really theirs.. Therapists need to work hard to help parents feel that they can make good decisions, even in the face of a problem they know little about. So, the new relationship between parent and therapist often begins in an atmosphere of high emotion -- fear for the child's well being, uncertainty on the parent's part, and a reluctance to relinquish control. When the parent is also a stutterer, all of these emotions are heightened. They are more afraid for the child because they know how bad stuttering can be. They are more uncertain about their ability (although in fact they are in a better position to support the child), and they are even more reluctant to relinquish authority to a therapist who doesn't understand stuttering from personal experience.
Therapists should enter this new relationship with a sense that the parents take their role very seriously, are well-motivated, and love their children beyond expression. Here and there, a parent may not fit this description, usually because of some other serious problem such as mental illness or an addiction, but I think it is very useful to begin by assuming the best.
The most important thing that the therapist can do, in my opinion, is simply listening to what the parent says, believing that what he or she tells you is true, and understanding the feelings behind the statements that the parent makes. In addition, it is important that the parent know that you are listening in this way, so you must communicate your attention, interest, empathy, and understanding. By being this kind of a listener, you demonstrate your own willingness to learn about the family, your interest in being a part of the solution, and your openness to accept the parent's point of view. Simply listening in this way gives therapists the information they need to begin treatment, and establishes a relationship with the parent that will facilitate treatment.
But there is more than that. By modeling openness and understanding, therapists are also able to demonstrate in the hear and now how parents can listen to their children. By showing the parents, through choice of language and nonverbally, that they are not afraid of stuttering, that they do not find it repellant, and that they find the child delightful regardless of the stuttering, the therapist is able to be a model of the kind of attitude that the parents will be developing during treatment. Of course, therapists will not be spending all of their time talking to the parent. Some of the clinic time will be spent with the therapist talking to the child, which is an important aspect of treatment but not the topic of this paper. However, during the time that the therapist spends with the child, he or she will also be modeling for the parents the kinds of values and behavior that they will be learning to use when they talk to the child at home. So, even the clinic time that is devoted to direct therapy with the child, is also an important part of parent counseling.
Responding nonempathically. When therapists are not well in touch with themselves, they may not realize that the discomfort parents feel about their child is often taken up by the therapists. It is not comfortable to hear parents expressing strong fears, or anger, even disgust at their child's difficulty. And many young therapists try to terminate their own discomfort at bearing witness to the parents' discomfort by reassuring, denying or minimizing the parents' feelings. Particularly, with very young children, where the success rates are so high, it is tempting to try to tell the parents early on that they really don't need to worry so much, that the child will probably end up speaking normally. True as this information is, it is not always what parents need to hear first. First, they need to know that they have been heard and understood on an emotional level.
Not letting them feel responsible. Therapists who have developed, either through their training or on their own, a strong sense that they are taking on an important professional role may make the mistake of taking on too much responsibility for the child's welfare. Parents may resent this, or they may feel less competent. Therapists who leave in the parents' hands the final decision about implementing all aspects of the therapy plan will find that the parents are more cooperative and compliant.
Giving advice. There are very few activities in the treatment of stuttering that are intuitive. If there were, therapists would be out of business. So, usually, the therapist must do much more than simply suggest something that the parents must do. Typically, parents need to be trained, with careful opportunities for reinforced practice of the behaviors they must show to their children. Nowhere is this more evident than in getting parents to talk more slowly to their children. Slowed parental speech is one of the best ways to reduce time pressure for the child and increase fluency. In many cases, but not all, it is all that needs to be done to return the child's speech to a normal level of fluency. However, parents cannot implement this strategy on their own, as a rule. They need to be trained in speech that is slower in rate but normal in pitch, melody, grammar, and pronunciation. Also, when parents are asked to demonstrate normal disfluencies to their children, normal that is, for the children (i.e. whole word and whole syllable repetitions), they will need to practice this skill before they can perform the disfluencies without also showing the child that they are uncomfortable doing so. Discomfort would, of course, send the child exactly the wrong message.
Power struggles. Because of their sense of responsibility and their simultaneous insecurity, parents of preschool children are inclined to be resistant to treatment. They are suspicious. Often, they have already discovered that their pediatrician, who is otherwise a marvelous source of information about their child's health, knows nothing at all about stuttering. Some pediatricians do not mind revealing their ignorance about this disorder, but many will try toact as if they do understand the disorder and will give inappropriate advice to the parents. Usually, the parents see through this quickly, which is why therapists see them in the speech clinic. But in the process of encountering their pediatrician's flaws, they may have come to mistrust any and all child authorities. Often too, sad to say, they have encountered some speech pathologists who do not know what they are doing, and then, of course, they are even more suspicious. So, they are inclined to be resistant to treatment. Of course, they can't readily admit to this resistance because they have come to the therapist for help, and this suggests that they will or ought to be compliant with the therapist's suggestion. As a result they often hide their resistance, masking it in some way or giving no more than lip service to the implementation of the therapy plan. One parent that I know, a stutterer herself, received identical recommendations from three respected authorities on stuttering, which included, in all three cases, that she be in therapy herself. Nevertheless, she steadfastly resisted implementing this important part of the treatment plan. When the child did not recover as completely or as quickly as expected, she was markedly angry at the therapists.
Dealing with resistance is never particularly easy, but the first rule is to respect the resistance. It comes from a deep-seated antagonism between what you have asked the parent to do and some belief or value that they hold dear. So, if you ask a parent to stutter in a comfortable easy way in front of their child so as to model an attitude toward stuttering of casual acceptance, but the parent believes that stuttering is acquired by imitation, they will resist the idea, even if they are not fully aware of their belief. It is important, in such a case, to uncover what belief or value the parent has that makes it hard for them to comply with your request. Another parent might have great difficulty in slowing their speech rate. As you look into this resistance, you might find a deeply held belief that people should be spontaneous at all times, making it difficult for the parent to change any aspect of their behavior. By respecting the resistance, and finding out more about it, these underlying values and beliefs can be discovered. Once discovered, it is possible to examine them and see if they are important enough to the parent to continue resisting treatment. Sometimes a parent will resist some aspect of treatment out of fear. The parent described earlier who refused to follow the recommendations of three different speech pathologists that she be in therapy herself did so because she was afraid of what that therapy might reveal. She had come to believe, largely through denial, that her own stuttering was no longer an issue for her, although it was obvious to anyone talking with her that it was still a very important issue. This belief, that her own stuttering was behind her, was in direct conflict with the suggestion that she enter therapy herself. She was simply not ready to give up the idea that her own stuttering was not a problem for her, and it is easy to see how this belief help her avoid substantial discomfort.
Get going. Therapy for families in which there is a preschool child who is speaking with excessive repetition, whether or not it is accompanied by struggle or avoidance, should get started without delay, in my opinion. Although it seems that there is a high probability of spontaneous recovery within the first few months after onset, there is no guarantee, and it is so easy to remove stuttering in this population, that it seems silly not to begin. And any delay, even of a week, runs the risk that the child will become frustrated, start to struggle, or discover accidentally that when he or she blinks, or nods, or grimaces the word will come right out. It only takes a few occurrences of one of these events to reinforce the child and lead to increased complexity and effort in speaking. The only argument for waiting is that it might save the parents some money and time. It might do that, but at the risk of costing them a great deal of money and time later on.
Respect the Parents' Role. I have discussed the importance of respecting the parents' role already, and do not need to do so again, but it is a vital part of parent counseling and should be understood to be a part of any plan of treatment.
Listen well. Listening too has been discussed. It is the first thing the therapist must do, however, so it is wise to have it in your plan from the beginning.
Model both values and behavior. The therapist is the model for everything. Watching the parent work directly with the child, the parent will see how to support and encourage the child, how to remove the various demands that might create additional opportunities for stuttering to occur, and how to build up the child's capacity to experience disfluency without frustration, fear, or shame. And, when the therapist is talking to the parent, there are additional opportunities to model for the parent an attitude toward stuttering that is open and accepting of the reality of the situation by using language that is clear and direct, noneuphemistic, and supportive.
Support first challenge later. In any therapy, the person must change. That is the whole point. But change is not easy. It may be frightening. It may raise very old business from childhood for the parents, issues laden with fear, shame or guilt, insecurities about parenting. All of us develop a kind of balanced way of being in the world, and a change will throw us off balance for a while. Consequently, therapists can make sure that parents are well grounded, with a solid base of information, knowledge that they are supported and accepted, that they trust the therapist not to ask them to do too much too soon, or to do something that is not well founded in scientific research and good clinical practice.
Have parents talk to parents. In my practice, I have often found it helpful to encourage parents to talk to other parents. They are able to support each other in ways that a therapist cannot. They are going through the same kind of experience, some are further along than others, but always their joint wisdom is greater than their individual wisdom. The convening of parents can be quite formal, a regular therapy group, in which case they will be able to work on issues they have with their parents. From this work will come insight and understanding into their own parenting style, and ultimately there will be benefits for the children. But it doesn't have to be so formal. Often, just helping parents keep in touch with other parents by sharing telephone numbers or arranging for them to have some time to meet, without the application of any therapeutic strategy, is also helpful.
Keep going. Recovery from stuttering seems usually to follow a negatively asymptotic curve. There is very rapid progress in the beginning, and then, as sessions go on the progress continues more slowly. It is easy to get discouraged as each session seems to bring less and less additional benefit. I think it is important to keep going. Often, growth in the child's ability to understand the issues, or their metalinguistic skill, or their speech motor control, will create an opportunity for a sudden breakthrough. Then too, sometimes people learn something but don't figure out how to use it until some later time. This could be said both of children and their parents. Another reason for continuing therapy even when little additional progress is seen is the possibility that something genuinely important will be discovered. One case continued long past the time when we would have recommended discharge. The child was fluent in all settings but one -- his home. The parent wanted to continue treatment, so we did for quite some time with little additional improvement, until one day, through the probing of an especially gifted student, we discovered that there was a gambling addiction in the family. Typically, the family had kept it a secret from us, but with its discovery came our understanding of the fears, even terrors, that the child had -- of his father's possible arrest, of violence, of sudden poverty, etc. We would never have discovered this important piece of information if we hadn't continued treatment well past the normal ending point.
School aged children vary so much in age that it is difficult to generalize about them. Some need substantial support from parents. Others need none at all. And it isn't just age. Some parents, doing what they think is best to help their child recover from stuttering, become real nags, pestering their children to practice, or to slow down, or to "use the techniques". Children are able, as any parent knows, to stop hearing things that they don't want to hear, and they will quickly tune out their parents' suggestions if they want to. After that, all the parents' continued pestering does is build up a well of resentment that is unhelpful. So, in a number of cases, I ask parents to simply stay out of it. When I have done this, the parents, typically, are relieved. They really don't want to be nags, and they know as well as the child that it wasn't helpful. But not all parents have gotten into this situation, so therapists should ask the children whether they want their parents to "remind" them to use a technique. If they say no, it is wise to respect their decision.
With adults who stutter, unfinished business with parents can often be an important source of issues that need to be resolved. And doing so can be a major benefit to the person trying to recover from a lifetime of stuttering. This kind of work should of course be done by someone qualified to do it by virtue of training in some psychotherapeutic technique. The best possible way to achieve this is for the speech therapist to get the necessary training. It may take some time to do it, but therapists who have done so, find an immediate benefit in being able to work on parental, and other, issues that stuttering brings up. If a therapist hasn't the time or money to expand his or her skills in this way, then they will need to refer to a psychotherapist. But it is important to make sure that the psychotherapist knows enough about stuttering to be helpful. Many do not have an adequate base of information and will be guided by their own theory of what stuttering is. In my experience, they are almost always way off base when they approach a stutterer in this way. Others will be able to listen, either to the therapist or to the stutterer, carefully enough to gain the knowledge they need. Finding psychotherapists like this takes a good deal of time, more probably than is practical, which is why I encourage the speech therapist to get the training. But it is important to help stutterers work on old issues of shame, parental denial of stuttering, misunderstandings, failures to communicate, and many others.
Much of the time, the therapist cannot talk directly to the parents of an adult stutterer, but that is not really a problem because the important communication that needs to take place is between the stutterer and his or her parents. Even in this case, it may be impossible to have direct conversations. The parents may have died, or the legacy of miscommunication and noncommunication may be so powerful that the resuscitation of a communicative relationship about stuttering is out of the question. But a great deal of healing work can be done by having the stutterer have an imaginary conversation with the parent, and it is best, when this is done, to have the stutterer take both sides of the conversation, saying first to the parent what needs to be said, and then switching roles so that the stutterer answers as the parent would. This kind of a conversation can be very helpful in healing the relationship between the two and in this way taking care of the unfinished business that remains.
Another solution is to have the stutterer write letters to the parent that are never sent. Answering letters can also be written. In this, as in the imaginary conversation method described in the preceding paragraph, a substantial amount of healing within the stutterer can occur. The resolution of these old issues can be quite important in helping the person develop a newer, simpler, and healthier attitude toward stuttering, which will in turn lead to more fluent speech.