About the presenter: Judith Felson Duchan is emeritus professor from the State University of New York in Buffalo. She has authored five books, is working on four more, and has published many chapters and articles on various aspects of language acquisition and loss. She is on ASHA's Inaugural Cadre of Advisers in Childhood Language Disorders, and a ASHA Board Recognized Specialist in Child Language. She is currently doing archeological work to find out about the early history of speech-language pathology in America, much of which concerned the treatment of stuttering.

You can post Questions/comments about the following paper to Judith Duchan before October 22, 2002.

Tough Love and Other Shady Stuttering Practices, Then and Now

by Judith Felson Duchan
from New York, USA

In 1881 Edgar Werner (Werner, 1881, p. 126 warned all those who stutter: Stutterers, beware! There are so much charlatanism and swindling practiced by many who pretend to cure impediments of speech, that I feel called up to give a few hints of precaution to speech-sufferers who may wish treatment but who may not know how to discriminate between the good and the bad teachers. I would, therefore, say--

Werner's cautions are interesting to us today, since they give us a sense of how ethical practices vary with the times. For example, in today's environment we do not censor stuttering clinicians that have therapy branches, who have their own methods that they "license" others to use, who see stuttering as physically based, who charge too little, or who collect a fee before the treatment. And to my knowledge we don't expect to encounter problems such as spelling or grammar mistakes in published materials, therapy methods kept secret, or promises of quick cures. But we do still worry about modern day practitioners who promise cures and who give a false sense of fluency or a sense that overcoming stuttering is impossible (see Kehoe, 2002).

Today, if we were to encounter what we consider to be malpractice or charlatanism, we might, like Werner, want to press charges, to warn others of the person's questionable practices, or, at least, to raise questions about the individualšs competencies or ethical practices.

The American Speech-Language and Hearing Association is the group working today to set standards for ethical practices in the area of stuttering therapy and to appeal to when someone does something that we would classify as malpractice. ASHA's code of ethics replaces Werner's cautions as a way to protect those who stutter. Consumers who stutter today need to beware of anyone violating ASHA's code of ethics -- a code that aims to hold speech-language pathologists to the "highest standards of integrity and ethical principles. . . ." (ASHA, 2002, p. 1).

ASHA's code is organized under four main principles, one about how they should treat clients, one about working within and improving their own competence, one about their obligation to the public and the last about their responsibilities to their profession and to colleagues. Here they are, in ASHA's words:

My guess is that Edgar Werner would have said that these principles are too general to rid the country of "charlatanism." For example, well- intentioned clinicians then and now would maintain they were concerned about the welfare of their clients, that they were maintaining the a high level of competence for the day, that they were fulfilling an unmet need of the public by providing services to stutterers, and that they were exempt from complying with professional standards, since there were none then. And how would one tell the difference between someone who claims to be well intentioned and someone who is a charlatan.

ASHA's code of ethics also contains more specific rules. They too are subject to one's interpretation. For example, item A under the first of ASHA's principles is "Individuals shall provide all services competently." Werner's journal was the arbiter of competence then, ASHA is today. But what standards are used to evaluate whether the person is providing services competently? For most areas of speech and language disorders, the standard can be one of observed improvement in particular domains of communication or social interaction. For example, one can judge improvement as fewer stuttering blocks or as coping better with disfluencies (Yaruss & Quessal, 1999). These improvements are, in turn used as evidence that clinicians are competent.

But stuttering offers a special problem when defining competence, both in Werner's day and nowadays. That is that people who stutter can improve under the direction of incompetent clinicians. But the improvement does not last. That is perhaps why quackery in Werner's day such a hot issue and unethical practices associated with stuttering are more difficult to monitor today than unethical practices for other areas of speech-language pathology.

This mercurial nature of stuttering plagued our founding fathers as much as it does clinicians and clients today. In the 1930s when our profession was established as a separate discipline, Wendell Johnson talked about his past therapy with someone he considered to be a charlatan. The basis of his critique was not that he didn't become more fluent, but that the newfound fluency didn't last. His critique could easily apply today to any therapy method being used for improving fluency. Conditions in a clinical interaction tend to result in fluency that fails to carry over to "real world" conditions. Here are excerpts from Johnson's vivid description:

". . . I had gone to a distant city in the summer of 1923, to be treated for my speech defect. There was a "stuttering school" there which advertised itself alluringly, and held out a promise of free speech which appealed to me tremendously. In over twenty years it has drawn to it hundreds and hundreds of stutterers; I hope, but I doubt, that the others fared better than I. The slowness with which bona fide speech clinics have developed, and the desperation and relative ignorance of the stutterers account largely for the prosperity of such "stuttering schools" -- if I may be allowed to express my own opinion."

". . . Everything was prepared for fluency. There was rhythm, even to the extreme of swinging Indian clubs. There were exercises to insure good physical health. There was an atmosphere of calm and confidence. I did not stutter very much under those circumstances, especially whenever I diligently employed the drawling monotone in speaking.'

". . . Whenever I left the "institute" and went down into the city, I stuttered! I stuttered because, so it seems to me, the higher neural centers were constantly being disturbed in the world outside the "institute" for the conditions there were radically different. After spending three months in the diligent use of "Nature's Method" I returned home‹stuttering just as much as ever. The world at large is never like the "institute," and that is why environmental therapy, such as was used there, is generally impractical. Of course, the stutterer can talk if he is given that much of a chance, but the world never gives him that much of a chance or anything like that much. Unless the stutterer wants to remain in an institution all of his life, he had better face the facts of the world he has to live in."

"After spending three months at the "institute," I left one morning in a moment of thorough disgust. I had gone to the "institute" with high hopes, and I had found to my great delight that I could talk if I drawled my words slowly enough and calmly enough. I had been overjoyed. But the truth was bound to come to me sooner or later, and when it came it was a catastrophe. I said good-by to nobody; I went to the station, stuttered to the ticket agent and to the conductor, and sat down wearily in a red plush seat. As the train crept out of the city, I closed my eyes in despair. I have hated that city ever since" (Johnson, 1930, pp. 81-84).

One way that has been developed to handle the difference between the comfort of the therapy room and the harshness of the real world conditions is to artificially institute difficult and sometimes demeaning speaking conditions in therapy. Many clinicians will recall those who stutter being required to put themselves in harsh situations (approaching strangers, speaking in public, standing on a table and talking, being harangued when talking.)

The tough love tactics of highly respected stuttering clinicians such as Charles Van Riper and Edward Lee Travis are legend. Van Riper has described himself as having a "cruel streak" (Williams, 1999) and various clients of his have described, in appreciative terms, his insults, his being a hard taskmaster, and a difficult person to please. He often rejected bids from consumers to work with him, making them feel "unworthy" of his attention (see Williams, 1999).

What this "tough" clinical approach raises for me a question of professional ethics that has not been directly addressed either in Werner's cautions nor in ASHA's ethical principles and rules. How does one protect the client from a clinician who is overexerting their power? When should "tough" approaches be considered abusive? There tends to be very little worry among those who are dealing with the ethics of practice for following the Golden Rule -- doing unto others as you would have them do unto you (Duchan, 2000). Nor is there protection for clients whose clinicians are too mean to them.

We have come a long way in improving our professional conduct toward those who stutter. We no longer see promises of cures nor do we need to worry about what it means to be qualified. But, because of the problems peculiar to stuttering, improvement is quixotic and tends to lead clinicians to institute challenging practices that prepare their clients for real world speaking stresses and indignities. I suggest that we include in today's codes safety mechanisms that protect clients from clinicians who may be unknowingly or knowingly abusing their professional power. What would you do about a clinician who is being too tough on his clients who stutter? Would you report them to ASHA's Ethical Practices Board? Would you warn others about the person's cruel practices? If you do nothing, would you be irresponsible? Should Edgar Werner or ASHA have added people like you to their lists of who to beware of?

References

American Speech and Hearing Association. (1994). Code of Ethics. Asha, 36 (March, Supplement 13), 1-2.

Duchan, J. (2000). What would Mrs. Doasyouwouldbedoneby think of speech therapists in America. Available: http://www.acsu.buffalo.edu/~duchan/goldenrule.html.

Johnson, W. (1930). Because I stutter. NY: D. Appleton & Company.

Kehoe, D. (2002). Overcome stuttering in six months: A multifactorial guide to speech therapy. Available: http://www.casafuturatech.com/Book/Overcome/index.html.

Yaruss, S. & Quessal, R. (1999). Preliminaries to treatment outcomes research for adults who stutter. Website: http://www.mnsu.edu/comdis/isad2/papers/yaruss2.html.

Werner, E. S. (1881). Stutterers, beware! The Voice, 3, (9), 126.

You can post Questions/comments about the above paper to Judith Duchan before October 22, 2002.

August 5, 2002