This is a threaded discussion page for the International Stuttering Awareness Day
Online Conference paper, The Impact of Identifying Preferred Treatment
Outcomes on Conceptualizing, Assessing, and Treating Chronic Stuttering by
Eugene B. and Crystal S. Cooper (Florida, USA).

Measuring outcome

From: Ed Feuer
Date: 10/14/98
Time: 6:43:48 PM
Remote Name:


As a consumer, what I'd like to see is independent third-party, scientifically valid efficacy data over time such
as one- three- and five year terms. Such research would look at the person who stutters speech in a variety of
situations. The researchers would also speak to the people with whom the person who stutters comes into
contact with on a daily basis. We know that in answering how's-your-speech-now questions posed by people
from the delivery program, there is the potential contaminating factor of ex-clients not wanting to admit failure
and not wanting to admit "letting down" the people with whom they worked.

Re: Measuring outcome

From: Eugene B. Cooper
Date: 10/14/98
Time: 6:44:11 PM
Remote Name:


Ed: Thanks for your comments. The major thrust of my coments was aimed at how we must develop clinical
instruments to assess the AFFECTIVE and COGNITIVE components of the problem as well as the
Behavioral components. It was also recognized that the perspectives of clinicians, parents, society, and
third-party payers must be considered in any determination of clinical efficacy. As you suggest, assessing the
significance of a stuttering syndrome is no simple task. I do think we're doing better.

Counseling, counseling,...but what type?

From: Gunars K. Neiders, Ph.D
Date: 10/14/98
Time: 6:44:55 PM
Remote Name:


Mr. Cooper, 

Thanks for the well written paper as well as the illustration of the 7 point scale. I commend you for advocating
both the affective and cognitive elements both in counseling and in the outcome measurement. 

When I studied psychology in early 1960's there were already 36 More or Less Mainstream Psychological
Therapies as documented in Robert Harper's book, Thirty Six Therapies (circa 1956). More or less each of
these therapies claimed to be "counseling". What do you mean when you say "counseling"? Is it based on any
particular psychological theory? Is it eclectic? But even if eclectic, where does it take its processes/methods
from? Has there been any study which type of therapies are most beneficial in stuttering therapy? 

I will for nonce not go into my preferrences ;-) (the smiley face is meant for those who know me), but don't
you think there better be some thought given to which counseling/therapy model we follow? Surely all
therapies cannot be equally effective, since they are so divergent in their approach and even desired outcomes. 

Re: Counseling, counseling,...but what type?

From: LH
Date: 10/14/98
Time: 6:45:16 PM
Remote Name:


Gunars, I couldn't think of anything more foolhardy than endorsing any particular counseling procedure.
Counseling that suits you would probably not suit me at all. That is the "art" part of counseling, and we all
know that you can't quantify art. A good counselor, a good therapist, or a good teacher of any sort, will
cut the material to suit the client or student. If they can't do it, the competent will admit it and send the
seeker elsewhere. However, if there is a rule book that specifies a particular approach, the incompetent
excuse his failure by thumping on the book, and blame the client. Is that really what you want? 

Lou H.

Re: Counseling, counseling,...but what type?

From: Gunars
Date: 10/14/98
Time: 6:46:38 PM
Remote Name:


Lou, If we were so inclined we could argue until hell freezes over, and one day thereafter, ;-) whether
counseling is pure art or pure science. I believe that counseling is neither, but a combination of the two. And
as people become more aware of their "inner workings", it will become more of a science. If my hypothesis is
right, then what I have asked are valid questions. As for our argument, let us agree to disagree. Respectfully,

Re: Counseling, counseling,...but what type?

From: Eugene B. Cooper
Date: 10/14/98
Time: 6:45:54 PM
Remote Name:


Dear Gunars: 

Thank you for your response to my article. I'll try to be brief: 

I use the term "counseling" to refer to a helping relationship that addresses feelings, attitudes, as well as
behaviors. I view helping relationships as falling on a continuum from "instructional" (focusing primarily on
behavior) to "counseling" (focusing on the ABCs- affective, behavioral, and cognitive components of the
client's problem, and the "psychotherapeutic" relationship typically required to address pathological disorders.

As you suggest, the literature is filled with descriptions of counseling type helping relationships. And as you
also suggest, the kind of counseling relationship applied will be dependent upong the nature and needs of the
individual entering into such a helping relationship. 

Fortunately, there are many counseling type helping relationships that have "stood the test of time." Some of
us go back to the days of Carl Rogers who described a relationship process that focused on assisting clients to
cope with their own "problems" through a supportive and nuturant environment. Of course I am referring to
what became known as Client Centered Therapy. That therapy, like so many of the currently available
counseling processes, was based primarily on the "field theory" that simply stated that most behavior is
determined by the individual's understanding, or lack thereof, of his or her world. Through "counseling," a
clinican's goal is to assist the individual seeking help to develop a more accurate perception of their situation.
With clients' more accurate perceptions, the assumption is the client will adopt more productive coping

Again, thanks for your comments. I trust you have found my remarks to be responsive to you. 


slp training

From: Joann Bergemann
Date: 10/14/98
Time: 6:47:14 PM
Remote Name:


Do you feel tapping into the emotions could open up counseling areas we as SLP's are not prepared or trained
to handle? 

Re: slp training

From: Walt Manning
Date: 10/14/98
Time: 6:47:44 PM
Remote Name:


A good question. Lots of time SLPs (especially new ones, and depending on the program they come from)
don't have much training in counseling. And, if they are new, may not have much life experience to give them
a hand. Having been around awhile will give you opportunities to experience and (maybe), survive, learn
from it as much possible, and become a bit wiser. Most of the time such experiences will help you relate to
those experiencing the pain of stuttering. But, most people have experience shame, helplessness, loss of
control and if the clinician is genuine and open in the treatment relationship, it provides a chance to link with
the experiences of the PWS. Most people who stutter are pretty regular people who happen to stutter for
whatever reason. Don't ever let a PWS tell you that "your not a stutterer and you can't understant". It may not
be easy but you and your client are more similar than you are different. Have them tell you their story
(assuming they feel safe enough to do this) and you'll find that you also have similar experiences in your life
that will help you understand and relate to the client. Don't know if I've been any help here or not....I guess
the bottom line is that much of counseling is listening with undertanding. If you truly know the culture of
being a PWS you'll be OK and you really don't need to worry much about somehow "hurting" a client. 

Re: slp training

From: Eugene B. Cooper
Date: 10/14/98
Time: 6:48:15 PM
Remote Name:


Your question concerning how to know when a clincian should seek assistance in handling or responding to
client expressions of feeling or disruptive thoughts is one which every counseling clinician faces. There is no
easy answer to this. In our discussions of the issue, we start with noting that our professional code of ethics
clearly states that we should not provide treatment procedures that are beyond our competencies. Simply, that
means if we do not feel competent in meeting the client's needs, we should seek assistance. 

My wife, Crystal, and I, in our Clinician's Manual for our Personalized Fluency Control Therapy Program,
discuss the issue in more detail. We suggest that the type of helping relationships needed to address client
problems can be productively viewed as being dependent on three critical client variables: 

1. The extent of the clien'ts misperceptions 

2. The extent of the affective overlay to the client's behaviors being addressed 

3. The extent of the affective/cognitive disparity the client experiences 

Placing these three client factors on a continuum from Low to High, we then draw a parralel continuum of
"Type of Helping Relationship" ranging from instructional, counseling, and psychotherapeeutic. The
assumption is made that client's demonstrating accurate perceptions of their problem(s), have few feelings
regarding their problem, and who think as well as feel the same way about their problems and the
ramifications of those problems, can benefit from an instructional type relationship. Those client's whose
misperceptions, feelings, and attitudes are extensive, handicapping, and conflicting will undoubtedly warrant
a psychotherapuetic type helping relationship. Those who fall in the middle of the continuum will need a
counseling type relationship. Again, we assume that clinician's will know the extent of their ability to provide
instructional and counseling type relationships. We know that many masters degree level (and beyong)
clinicians are comfortable in handling various types of counseling relationships. Our bias is that stuttering
syndromes, by virtue of the significance of the affective and cognitive components of the disorder, invariable
warrants a counseling type helping relationship. 

Thanks for the great question. 

Eugene B. Cooper

cooper on counseling

From: Jerry Johnson:
Date: 10/14/98
Time: 6:48:51 PM
Remote Name:


I have wondered where Dr. Van Riper might be and now I know. Congrats on you counseling approach to
stuttering along with all the other goodies that go into changing human behavior. Nature or nurture? Let's get
beyound counting stuttering symptoms and start dealing with the real person

Re: cooper on counseling

From: Eugene B. Cooper
Date: 10/14/98
Time: 6:49:20 PM
Remote Name:


Thank you for your very reinforcing comments! We obviously think alike, at least on this matter. 



From: Chuck Goldman
Date: 10/14/98
Time: 6:50:00 PM
Remote Name:


As a memeber of ASHA's SID 4 and a long time follower of the Coopers' work I applaud the direct and
concise manner in which this paper was presented. We who know stuttering most intimately know of the need
to measure stuttering via a multidimensional paradigm. How do we sell this to the health insurers of America?
Are the precedents in our field for this type of FCM or are we treading on new turf?

Re: FCMs

From: Gene & Crystal Cooper
Date: 10/24/98
Time: 10:01:50 AM
Remote Name:


Dear Chuck: 

Thanks for your comments. This is our second attempt to respond. We think our first response has gone on to
internet heaven somewhere, so we'll try again (of course this response will nowhere near match the brillance
of the one lost in space. 

One of strategies that the Special Interest Division is pursuing in attempting to identify and assess preferred
treatment outcomes (for the purpose of determining the efficacy of treatments) is to identify just what treatment
outcomes are being sought by the those who stutter, their clinicians, parents, society, and the third-pary
payers. We belive we've done well in understanding what clients and clinicians want and we're now focusing
on identifying what other constituencies expect and want as a result of stuttering treatment. So I think we're
on the right tract. We'll soon be talking about preferred outcomes that can be measured and understood by all

The day of the 'Frequency Fallacy' is passing, we hope. No more will the severity of stuttering be judged on
the basis of frquency counts! And hurray for that. 

AGain, thanks for your comments. 

Gene & Crystal 

Outcomes /quality of life

From: Harsha Kathard
Date: 10/15/98
Time: 4:09:29 AM
Remote Name:


Dear Eugene and Crystal Cooper 

Thank you for a most interesting presentation 

I have a few questions- I teach speech pathology at a University in South AFrica and have followed your
work closely- i agree that the ABCs must be included in outcome measures. Whilst i acknowledge that our
role relates primarilyto the communication disorder and its impact- the outcome in often realised in
iprovement/changes to quality of life as a broader measure- have you considered drawing from " quality of
life" instruments when attempting to measure outcomes- do you think that this broader measure is the role of
another professional-e.g psychologist? I think an outcomes based appraoch to clinical practice and training is
very useful- have you used this in student training? In the context in which we presently practice -we engage
in cross-cultural work routinely Counselling in some instances is a very difficult task expecially when clients
and clinicians often do not share a common language or first language. In such instances- hence the focus may
be greater on the fluency shaping aspects- do you have any suggestions for how to deal with such difficulties
when attemping to evaluate outcomes. 

Thank you 

Re: Outcomes /quality of life

From: J. Scott Yaruss
Date: 10/15/98
Time: 7:29:54 AM
Remote Name:


Hi Folks...I know this isn't my forum and I'll look forward to Gene & Crystal's response. But, I couldn't
help throwing in a brief response to Harsha's question about Quality of Life. I believe that assessing QOL is
an important indicator of overall gains in treatment and changes in the impact of stuttering on the client's life.
Unfortunately, none of the available QOL instruments are particularly applicable to stuttering. That is why we
have been developing and testing a QOL instrument focused specifically for stuttering. It draws from existing
instruments but tailors the responses so they are more appropriate for this disorder. I describe it briefly in my
paper as part of the ISAD on-line conference. Thanks! Scott

Re: Outcomes /quality of life

From: Eugene B. and Crystal S. Cooper
Date: 10/24/98
Time: 9:10:26 AM
Remote Name:


Harsha Kathard: 

Thank you for your response to our paper. Shifting the focus from behavioral components to broader aspects
indicating quality-of-life changes in those experiencing a stuttering syndrome is one of the more positive
features in the state-of-the-art of assessing the efficacy of therapy. Fortunately, many instruments have been
developed to assess key elements of affective and cognitive as well as behavioral changes relating to stuttering
treatment. We need to do more in making such instruments available to our clinicians. J. Scott Yaruss'
comments indicate but one example of current attempts to develop more comprehensive assessment
instruments designed specifically to address the cognitive and affective components of stuttering syndromes.
Concluding, as we have for many years, that the chronic stuttering results from the INTERACTIONS of
multiple co-existing physiological, psychological, and environmental factors, We view the attention to the
cognitive and affective features of the syndrome as critical to the synrome's assessment as are the behavioral

We believe it is the primary responsibility of our discipline to lead in the development of instruments to
measure "quality-of-life" factors in those experiencing stuttering syndromes. Obviously, as we struggle to do
so, it is and will be to our advantage to know what other disciplines have done in developing such measures.
We assume those focusing on stuttering assessment and treatment are better equipped to tailor assessment
instruments to the problem of stuttering than are those committed to the development of instruments for
assessing "universal" factors in the quality of life. 

As you note, counseling may become problematic when the ethinicity of counselor and client are markedly
different. No doubt about it. However, we maintain, that to ignore the affective and cognitive components of
the disorder and to proceed with behavioral intervention strategies, is to invite disaster. Until we know how
the client feels and thinks about the stuttering, we cannot develop the kind of comprehensive treatment plan
needed to address efficiently and adequately the characeristic affective, behavioral, and cognitive components
of stuttering syndromes. 

We are delighted that the American Speech-Language-Hearing Association's Special Interest Division for
Fluency and Fluency Disorders, for two years, devoted its annual leadership conference to treatment outcome
measurement. Already, we are seeing the results of that leadership in the numbers of our colleagues beginning
the construction of valid, reliable, and efficient protocols for assessing those factors that determine the efficacy
of stuttering treatment. 

Again, thanks for your thoughtful comments. We trust that our comments are responsive to your questions. 

Eugene B. & Crystal S. Cooper 

National Outcome Measurements

From: Luann Kane and Ruth Verschaetse
Date: 10/16/98
Time: 11:30:52 AM
Remote Name:


We enjoyed reading your article. One positive result of the NOMs for the treatment of stuttering would appear
to be that stuttering will be treated in a consistent manner throughout the country. By this we mean that all
clinicians who work with people who stutter wil be required to address the affective, behavioral, and cognitive
components, which may not be fully addressed in some cases. 

Since adults have been shown to judge success of therapy by how it has affected their feelings and cognitive
behavior, therapy should always fully include these.

Re: National Outcome Measurements

From: Dear Luann and Ruth:
Date: 10/24/98
Time: 9:47:51 AM
Remote Name:


Thank you for your kind words regarding our article. We share your hope that in he years ahead we will see
the assessment of the affective and cognitive, as well as the behavioral components of stuttering syndrome
being addressed in a valid, reliable, and efficient manner. Then, and only then, can we expect to see the
elimination of stuttering syndrome assessments relying solely on disfluency frequency counts. We've
described the "Frequency Fallacy" any number of times over the past twenty years (which states that the single
most valid measure of stuttering severity is the frequency of disfluencies count. Let's hope that such notions
are put-to-rest and all practicing clinicians will be assessing and attending to all of the factors that constitute the
stuttering syndrome. 

Again, thanks for you interest 

Gene and Crystal -