Stuttering Therapy Survive and Thrive Craig Coleman M

“ Stuttering Therapy: Survive and Thrive Craig Coleman, M. S. , CCC-SLP BCS-F Mary Weidner, Ph. D. , CCC-SLP WVSHA Convention Bridgeport, WV March 9, 2018

Disclosures o Craig Coleman § Financial: Co‐owner, Stuttering Academy; Co‐author, OASES–S § Non‐financial: Co‐director, Stuttering U; Member, SIG‐ 4 Board o Mary Weidner § Financial: Co‐owner, Stuttering Academy § Non‐financial: Co‐director, Stuttering U

Overview Assessment • • Defining stuttering Basic Facts Risk factors Causes – research update Observable characteristics Affective components Determining severity Clinical documentation Goals for today Management of observable stuttering Management of affective components • Preschool vs. School age • Stuttering modification & Speech modification • Overall communication • Counseling

Defining Stuttering o The public and professionals have difficulty providing a comprehensive definition of “stuttering” o Prior to a face‐to‐face stuttering training, only 1/24 certified SLPs accurately defined the comprehensive nature of stuttering (Coleman & Weidner, 2014)

Stuttering is… A disruption in the flow of speaking characterized by repetitions (sounds, syllables, words, phrases), prolongations, blocks, interjections, and/or revisions. These disfluencies may be accompanied by physical tension, negative reactions, secondary behaviors, and avoidance of sounds, words, or speaking situations. (ASHA, 1993; Coleman, 2013; Yaruss, 1998, 2004)

Stuttering vs. Disfluency o Stuttering § Not typical § Characterized by repetitions, blocks, and prolongations § Increased physical effort § May have negative reactions o Disfluency § Every speaker is disfluent (~3%) § Revisions, interjections, easy phrase repetitions

Stuttering vs. Disfluency o Repetitions o Prolongations o Blocks o Interjections o Revisions § Repeat a sound, word, or phrases over and over again. § Make a sound longer than it should be. Stuttering disfluencies § Get completely stuck and no sound comes out. § Extra words (um, uh, like) § Fixing errors Nonstuttering disfluencies

Defining Stuttering – Clinical Takeaways o Goals this might address: § Clark will be able to accurately describe the surface level characteristics of his own stuttering independently to at least 3 people § Audrey will be able to accurately describe the difference between blocks, prolongations, and repetitions § Eddie will be able to distinguish between the core and secondary behaviors of his stuttering § Ruby Sue will be able to identify and list the affective components of his stuttering using the stuttering iceberg

Defining Stuttering – Clinical Takeaways o o Even young children can define stuttering when given the right support or instruction After watching lessons featuring stuttering characters, 86. 5% of preschools (32/37) could define stuttering (Weidner, 2016): § § § § When your words get stuck They try to get the bounces out They sound out their words when they talk When people don’t finish their words fast like other people You do this ka-ka Your voice sounds a little jumpy Their words don't come out or their words stretch or they bounce

Defining Stuttering – Clinical Takeaways o Activities might involve using analogies to help children and parents think about stuttering in a new way. o You can use props, pictures, and activities to illustrate these: § § § Writing task Allergies Vision Chinese finger trap Iceberg Have the child come up with their own analogy

Observable characteristics Prolongations, blocks, repetitions Emotions and reactions Guilt, shame, fear, anxiety, frustration, withdrawal, etc.

INSERT SPEECH GUY

Overview: RISK FACTORS

Risk Factors o For young children, risk factors inform the prognosis for recovery or persistence of stuttering o Why does it matter? § Understanding risk factors helps the client, parents, and SLP to get their expectations in line with reality

Risk Factors Family history of stuttering Male gender Stable or increasing disfluencies Greater than 6 months since onset o Physical tension/secondary o o behaviors including subtle ones (pitch/loudness increases) Frustration/awareness Prolongations/blocks Later onset stuttering Other speech/language concerns o Parental concern o o

“ Risk Factors – Clinical Takeaways

Risk Factors – Clinical Takeaways o Understanding risk factors can help a clinician address the question, “Will my child stutter forever? ”

Causes – Multifactorial Neurophysiology Genetics Demands/ Capacities Environment Temperament/ Personality

Causes – Clinical Takeaways o Understanding causes of stuttering can help a clinician address the question, “Why does my child stutter? ” § We can’t pinpoint the exact cause for every person who stutters, but we do know that there are strong links to genetics and how the brain works. People who stutter often use more and/or different parts of their brain when they talk. Other personal and environmental factors might also play a role.

Overview of stuttering references & suggested readings American Speech‐Language‐Hearing Association (n. d. ). Fluency Disorders in Childhood (Practice Portal). Retrieved month, day, year, from http: //www. asha. org/Practice‐Portal/Clinical‐Topics/Childhood‐Fluency‐Disorders. Cauvel, C. , Bleyle, L. , Coleman, C. , Sydenstricker, A. , Goble, E. , Stephens, L. , Childers, K. , & Fisher, B. (2014, November). Assessing speech language pathologists’ knowledge of stuttering. Presented at the annual convention of American Speech‐Language‐Hearing Convention, Orlando, FL. Coleman, C. & Weidner, M. (November, 2014) Stuttering U. : A summer camp for children who stutter and their families. Presented at the annual convention of the American Speech, Language, and Hearing Association, Orlando, FL. Drayna (2015, December). What Causes Stuttering? Stutter Talk Episode 560. Retrieved from www. stuttertalk. com. Drayna (2015, December). A Genetics and Stuttering Update. Stutter Talk Episode 560. Retrieved from www. stuttertalk. com. Domingues C. E. , Olivera C. M. C, Oliveira B. V. , Juste F. S. , Andrade C. F. , Giacheti C. M. , Moretti‐Fereira D. , Drayna D. (2014). A genetic linkage study in Brazil identifies a new locus for persistent developmental stuttering on chromosome 10. Genetics and Molecular Research, 13, 2094‐ 2101. Frigerio‐Domingues, C. , & Drayna, D. (2017). Genetic contributions to stuttering: The current evidence. Molecular Genetics & Genomic Medicine, 5(2), 95‐ 102. ‘

Overview of stuttering references & suggested readings Glover, H. , St. Louis, K. O. , Weidner, M. E. , Flick, M. , Garrett, A. , Chichilla, J. , Caudle, K. , Hatcher, A. , Flick, M. , Chichilla, J. , Öge‐ Dasdogen, Ö. (2017, November). Stuttering Attitudes of 4‐ 11 Year‐Old Children & Their Parents. Poster accepted at the American Speech‐Language‐Hearing Association, Los Angeles, CA. Raza M. H. , Gertz E. M. , Mundorff J. , Lukong J. , Kuster J. , Schäffer A. , Drayna D. (2013). Linkage analysis of a large African family segregating stuttering suggests polygenic inheritance and assortive mating. Human Genetics, 132, 385‐ 396. Raza M. , Riazuddin S. , Drayna D. (2010). Identification of an autosomal recessive stuttering locus on chromosome 3 q 13. 2‐ 3 q 13. 33. Human Genetics, 128(4): 461– 3. Quesal, B, , & Reitzes, P. (2012) Stuttering Analogies. Retrieved from http: //stuttertalk. com/stuttering‐analogies‐ 318/ St. Louis, K. O. (Ed. ) (2015). Stuttering meets stereotype, stigma, and discrimination: An overview of attitude research. Morgantown, WV: West Virginia University Press. Yairi, E. , & Ambrose, N. G. (1999). Early childhood stuttering I: Persistency and recovery rates. Journal of Speech, Language, and Hearing Research, 42, 1097‐ 1112. Yairi, E. , & Ambrose, N. (2013). Epidemiology of stuttering: 21 st century advances. Journal of Fluency Disorders, 38, 66‐ 87.

Overview Assessment • • • Defining stuttering Basic Facts Risk factors Causes – research update Preschool vs. School Age Observable characteristics Affective components Determining severity Clinical documentation Goals for today Management of observable stuttering Management of affective components • Preschool vs. School age • Stuttering modification & Speech modification • Overall communication • Counseling

Assessment o Purpose: § For preschool children – to determine whether or not the child needs § For school-aged children – to determine whether or not the child is ready for therapy and why they are coming for an evaluation now

“ Preparing for the Assessment

Preparing for the Assessment o For children of all ages, you’ll likely need: § A disfluency count sheet to count disfluent and fluent words or syllables • Access here: www. stutteringacademy. com or www. stutteringu. com § Stuttering Severity Instrument-4 to perform a standardized measure of stuttering § Recorded Speech samples from home or another setting

Preparing for the Assessment o For older children, you may also need: § Overall Assessment of the Speaker’s Experience of Stuttering (OASES). § The OASES assesses the life impact of stuttering relating to a person’s: overall knowledge of stuttering, reactions to stuttering, functional communication, and quality of life § Versions include: • OASES-A (18+ yrs) • OASES-T (13‐ 17 yrs) • OASES-S (7‐ 12 yrs) § Access here: https: //www. stutteringtherapyresources. com/menu‐oases

Preparing for the Assessment o For older children, you may also need: § Community Centered Stuttering Assessment (CCSA) § The CCSAs assesses the impact of stuttering on a child’s life as reported by familiar listeners § Versions include: • • Child Parent Teachers SLPs § Access here: www. stutteringacademy. com

“ Conducting the Assessment

Conducting the Assessment o Parent Interview (face‐to‐face, phone, or written responses) o Child interview (especially for older children) o Assessing the observable stuttering in various speaking tasks o Assessing the attitudes and emotions

Parent Interview Is there a family history of stuttering? Does the child have any other speech/language issues? Are there any other medical concerns? How does the child interact with others? Are his interactions impacted on by his stuttering? o What is the impact on social and educational activities? o Does stuttering prevent the child from participating? o Who else is involved in the child’s care on a regular basis? o o

Parent Interview How long has child been stuttering? Has stuttering changed over time? What types of stuttering is the child exhibiting? How much is the child stuttering? Is stuttering increasing or decreasing? o Does the child have any tension when stuttering? o Does the child seem concerned? o How are others reacting? o o

Child Interview (Older Children) o Child needs to be interviewed to determine: § Child’s readiness for treatment § Any differences in parent/child beliefs and reports § Child’s previous experiences in treatment § Child’s emotional response to disfluency § Child’s ability to use fluency strategies

Assessing the observable stuttering o o o o Conversation Story Retell Reading Picture Description Interaction with Parent Interaction with Siblings Interaction with Peers

Assessing the observable stuttering o Want to obtain % stuttered words in a speech sample (~200‐ 300 words) gives us a good representation o Divide total number of stuttered words by total number of words o For the SSI calculations, be sure to convert words to syllables. Multiply stuttered words by 0. 7

Assessing the observable stuttering o In addition to the amount of stuttering, determine: § Types of stuttering § Average length of stuttering events (for blocks, prolongations, and repetitions) § Average number of iterations (for repetitions) § Associated secondary behaviors during moments of stuttering (eye blinking, head nods, etc. ) § Associated tension during moments of stuttering (facial grimacing, pitch breaks, etc. )

Assessing the observable stuttering o Deja’s disfluency rate was 11% in conversational speech and 17% in an oral reading task. She exhibited moderate physical tension in the face and neck during periods of stuttering. She also exhibited secondary behaviors, such as head-nodding and hand-tapping. Deja exhibited repetitions (sound, word, and phrase), prolongations, and blocks. She exhibited repetitions of up to 6 iterations and average length of blocks/prolongations was approximately 3 seconds.

Assessing the affective component o Results from the OASES and CCSA can serve as a baseline for the affective/cognitive components o Children may be initially hesitant to talk about their stuttering emotions/reactions. Other approaches to start those conversations might include: § Books about stuttering § Videos featuring children who stutter § Drawings

Assessing the affective component o Sometimes I just stutter o Normalizes negative attitudes associated with stuttering o Free PDF download here: https: //www. stutteringhelp. org/sites/d efault/files/Migrate/sometimes_stutte r. pdf

Assessing the affective component o Tarby Comes Out of His Shell o Addresses negative attitudes, differences, teasing, and acceptance o Available for a short time through: www. stutteringacademy. com

Assessing the affective component o Stuttering for kids by kids o Features several children who stutter who talk about their experiences o Freely accessible through: https: //www. stutteringhelp. org /content/stuttering‐kids o Stay tuned for our video!

Assessing the affective component o Allow the child to express their feelings about stuttering through art o “How does stuttering makes you feel? ” o “What does it feel like when you stutter? ” o “What do other people do when you stutter? ”

Assessing the affective component o Use scales or images to assess how a child is feeling about or dealing with their stuttering �� �� ���� � § 1 – 10 § Likert (e. g. , not good to very good) § Emojis

“ After the Assessment – Determining if Treatment is Indicated

Determining if Treatment is Indicated (Preschool) o o Assess all risk factors Is stuttering increasing or decreasing? Age is not that important! See suggested guidelines at: www. stutteringacademy. com

Determining if Treatment is Indicated (Older Children) o Does the child want treatment? o What are the child’s expectations for treatment? o Can the clinician give the child and parents what they want? o What are the primary goals of the child and parents? o Is the child ready to make changes?

Overview Assessment • • Defining stuttering Basic Facts Risk factors Causes – research update Observable characteristics Affective components Determining severity Clinical documentation Goals for today Management of observable stuttering Management of affective components • Preschool vs. School age • Stuttering modification & Speech modification • Overall communication • Counseling

General Treatment Principles o Make sure that you and the child can describe the rationale for why you’re doing what you’re doing o We must do what we ask of our patients o Packaged or intensive stuttering programs can be very restrictive o Make abstract concepts as tangible as possible

“ Preschool Treatment

Preschool Treatment – Philosophy o Stuttering might be eliminated in many cases, but the message still should be that stuttering is ok and accepted o Otherwise, the child is trained to focus too much on fluency, and if they continue to stutter, it is harder to send the positive messages later

Preschool Treatment – Options o May being with: § Indirect treatment: Focus on teaching the family strategies to enhance fluency through environmental modifications § Direct treatment: Teach the child to use strategies and techniques § Operant: Praise fluency and reinforce need to say disfluent utterances again

Preschool Session – A Typical Session o o o Parent Education Interaction with Child Parent Observation Parent Involvement in the Session No matter what preschool treatment approach you use, parent involvement is consistently a core component

Preschool Treatment – Indirect o Involves making changes in environment, rather than making any changes to the child’s speech o Stuttering is not talked about with the child o Very popular through the 1980’s, especially when diagnosogenic theory was thought to be true

Preschool Treatment – Indirect o Start with approx. 4 sessions of parent training once per week for children ages 2 through 6 o Depending on progress: § 1. Monitor fluency over 3 months and reevaluate § 2. Begin direct treatment • OR § 3. Begin integrating direct treatment right away

Preschool Treatment – Indirect o Taken from Yaruss, Coleman, & Hammer (2006) § § § Reducing parents’ communication rates Reducing time pressures Reducing demand for talking Providing supportive communicative environment Addressing negative reactions Focus on content, not just manner

Preschool Treatment – Indirect o Slower than parents’ habitual rate, but not too slow, choppy, or robot‐like o Introduce phrased speech as a preferred way to reduce speaking rate o Explain that the goal for the parents’ speaking rate is somewhere in between the rate they will practice in treatment and the rate they used before treatment

Preschool Treatment – Indirect Use modified questioning to reduce time pressure o I wonder… o Maybe… o I think… o It looks like… o I bet… o Let’s see if… o I guess… o Why don’t we try…

Preschool Treatment – Indirect Use recasting and rephrasing o Child can hear what he or she said in an easier, more relaxed way o Child knows that parents have heard what he or she said o Gives parents the opportunity to provide a good language/articulation model

Preschool Treatment – Direct The “S” word: o It is okay to use the word stuttering, but some children may find terms such as “bumpy speech” more concrete o Each child will differ in how they “view” stuttering o Some children may be more sensitive o Maintain encouragement and reinforce their desire to communicate o Avoid negative words (e. g. , “That was a bad one. You are having a bad day. ”) o Conspiracy of Silence

Preschool Treatment – Direct o Direct treatment involves more specific activities involving the child that target improving fluency or changing stuttering o Teach various types of talking § § Turtle Rabbit Kangaroo Snake o Hard vs. Easy bumps o Easy starts

Preschool Treatment – Operant o Involves praise and negative reinforcement o Lidcombe is a well‐known example of this o Lots of cautions here

Preschool Treatment – What Do We Do? o Some combination of indirect and direct, depending on the child’s needs and the family’s needs o Stuttering is highly variable at this age o Progress is not usually linear

Sample Goals for Preschool Children Parents o Reduced communication rate o Use of indirect prompts rather than direct questions o Reduced time pressure o Increased use of recasting/rephrasing Children o Reduced communication rate o Easy starts o Reduced tension and secondary behaviors o Improved reactions o Increased communication

“ Transitioning out of Preschool – Treatment for Older Children

Older Children Treatment – Philosophy o As children get older, treatment is much more about successful management o Counseling skills become crucial as the child transitions to a school‐age child who stutters

Older Children – A Typical Session o Interaction with child (more conversation‐based) § Question cards (Table Topics) § Would You Rather… § Debates o Have child take lead on educating parents or others (when possible)

Stuttering Modification o These goals should target decreased physical tension during stuttering o Focuses on the way a child stutters, rather than if they stutter o Goals also target reduction of secondary behaviors

Stuttering Modification Strategies o o o Cancellations Pull‐outs Preparatory Sets Easing Out Note: In order to use these, you have to be stuttering!

Stuttering Modification – Sample Goals o o Rebecca will demonstrate the ability to reduce physical tension during stuttering using the “easing out” technique, for 50% of disfluencies during conversational speech with the clinician. Jack will use cancellation and pull-out techniques for 75% of disfluencies in a structured conversational task. Kate will be able to correctly identify location of physical tension during 80% of stuttering episodes in a structured task. Toby will decrease the use of any secondary behaviors associated with his stuttering to less than 10% of disfluencies.

Speech Modification o Also known as Fluency Shaping o Goals target reduction of the number of disfluencies o Goals should be viewed in terms of reduction, not how often children can speak fluently

Speech Modification Strategies o o Easy starts Light contacts Pausing and phrasing Prolonged speech

Sample Goals for Speech Modification o Randall will use easy starts 85% of the time in a structured conversation. o Beth will decrease the number of disfluencies in a structured conversational task by 15%. o Sophie will use pausing and phrasing 80% of the time in structured conversations with the clinician. o Kevin will identify times when he wants to use strategies and techniques.

Cautions on Strategies o Strategies can be learned very quickly and result in significant short‐term gains o Can be hard to generalize outside therapy room o Require a lot of effort on the part of the speaker o Target only surface‐level stuttering

Dismissal/Discharge Criteria o Discharge will depend on individual needs, but generally, children should have: § § § Good grasp of knowledge of stuttering Ability to use strategies when they want to use them Neutral to positive attitudes toward stuttering Little to no impact on overall communication Supportive communicative environment

Overview Assessment • • Defining stuttering Basic Facts Risk factors Causes – research update Observable characteristics Affective components Determining severity Clinical documentation Goals for today Management of observable stuttering Management of affective components • Preschool vs. School age • Stuttering modification & Speech modification • Overall communication • Counseling

Affective and Cognitive Components o Affective: Feelings and emotions associated with stuttering o Cognitive: Thoughts related to stuttering o Impact in the affective and cognitive domains can lead to reduced communication skills and negative experiences with speaking

Start with Education o Children need to be educated about stuttering (empowerment) o Education helps the child deal with stuttering long‐ term rather than getting a “quick fix” o Helps the child teach others, such as their peers, about stuttering o Helps them respond to questions, teasing, bullying

Education – Clinical Takeaways o Goals might include: § Michael will increase his knowledge about stuttering by scoring at 85% or better on periodic stuttering quizzes. § Pam will educate 2 -3 peers about stuttering. § Jim will give a presentation to his family members, peers, or teachers on stuttering. § Dwight will be able to identify and explain the process of producing speech and the anatomical structures involved in this process through use of drawings and other illustrations.

Education – Clinical Takeaways o Activities should be aimed to make the child the “expert” about stuttering o Online quizzes are a great way for children to learn about stuttering, and then challenge their family and friends: www. quia. com: class code TANPEC 388 o Drawing a “speech guy” can help the child learn the anatomy and physiology of the speech mechanism o Researching famous people who stutter can help a child to realize he is not alone: https: //www. stutteringhelp. org/famouspeople

Targeting Overall Communication o Probably the most important goals o Goals should heavily target avoidance or negative reactions to stuttering o Eye contact, turn‐taking, topic maintenance, initiating conversations with new partners, discussing the consequences of poor communication, and identifying the consequences of avoidance o Incorporate others important to the child (siblings, friends, parents, teachers, etc. )

Overall Communication – Sample Goals o Michelle will decrease avoidance behaviors associated with her stuttering by entering 3 specific situations where she previously avoided stuttering. o Tony will demonstrate desensitization to stuttering by using 5 pseudostutters during a conversation in the classroom. o Chloe will increase her participation in educational and social situations, as noted on a weekly basis by her parents and teachers.

Notes on Improving Overall Communication o Desensitization is critical o Opportunity to face situations that cause fear such as: § § § Talking to an unfamiliar listener (e. g. , school secretary) Ordering food Raising hand in class Talking on the phone Giving a presentation

“ Counseling in Stuttering

Counseling in Stuttering o Counseling plays a critical role in treating the holistic needs of the client o Much more than just a talk/listen relationship o Can serve many purposes § § Help clients “be heard” Help clients feel understood and validated Provides support Helps clients confront and deal with where they are on their stuttering journey

“ The goal of counseling is not to make people feel better, but to separate feelings from nonproductive behavior. ” –Luterman, 1996

Counseling in Stuttering – Scope of Practice 2007 • Counseling individuals, families, coworkers, educators, and other persons in the community regarding acceptance, adaptation, and decision making about communication and swallowing. 2016 • Empower the individual and family to make informed decisions related to communication or feeding and swallowing issues. • Educate the individual, family, and related community members about communication or feeding and swallowing disorders. • Provide support and/or peer-to-peer groups for individuals with disorders and their families. • Provide individuals and families with skills that enable them to become self-advocates. • Discuss, evaluate, and address negative emotions and thoughts related to communication or feeding and swallowing disorders. • Refer individuals with disorders to other professionals when counseling needs fall outside of those related to (a) communication and (b) feeding and swallowing. https: //www. asha. org/uploaded. Files/SP 201600343. pdf

Counseling in Stuttering o In stuttering, hard conversations are frequent o Topics of hard conversations are numerous and can involve many different emotions inadequacy, grief, guilt, fear, anxiety, frustration, etc. o When we avoid difficult conversations, we trade short term discomfort for long term dysfunction. - Unknown

Counseling in Stuttering We are not in the business of telling people how they should feel!

Help lead client’s through stages of change o Importance of stages of change: § Help us understand reasons for a person’s behavior § Help to guide our intervention so it is “stage appropriate” § Change is most effective when it follows the progression of the stages

1. Precontemplation Not aware of the issue, no intention to change 2. Contemplation Aware problem exists, thinking about changing but pros and cons might be equal 3. Preparation Intention to take action to change 4. Action Making modifications to behavior 5. Maintenance Have made modifications, in “remission”

Help Clients Think More Rationally _____ cause feelings.

Help Clients Think More Rationally o Our role is to help clients to identify and dispute irrational thoughts “self‐talk” o Irrational thoughts can impact self‐perception, actions, relationships, and physical health

Help Clients Think More Rationally Irrational pattern Definition Example All or nothing thinking The world is black and white I should not talk if I stutter. Overgeneralization One negative event is seen as a never‐ending pattern of defeat I get stuck on my “r” sound. I can’t say anything right. Mental filter Dwelling on negatives and ignoring positives I stuttered five times during that presentation. Discounting positives Insist that positives or accomplishments “don’t count” So what if I read out loud. Everyone else did too. Jumping to conclusions She will laugh at me if she finds out I stutter. Mind‐reading and fortune telling

Help Clients Think More Rationally Irrational pattern Definition Example Magnification or minimization Blowing things out of proportion They think I am stupid because I stuttered on my name. Emotional reasoning Justifying actions based on how I feel anxious about ordering you feel food so I’ll pack my lunch. Should statements Criticize self or others based on I should be fluent all the time. what they “should” do Labeling Identifying self or others based I am a terrible communicator on shortcomings because I stutter. Personalization and blame Blame self or others and neglect to recognize own contributions to the problem My stuttering prevents me from having friends.

Help Clients Think More Rationally A. Event or Situation B. Thoughts “self talk” C. Feelings

Help Clients Think More Rationally THE GOOD NEWS Even though stuttering might not go away, a person’s self talk can be changed to help him feel differently about stuttering.

Help Clients Think More Rationally Now what? 1. Identify the sentence they are telling themselves 2. Identify their type of irrational thinking 3. Dispute thoughts to improve their negative self talk • Replace the irrational sentence with one that is more rationale/accurate • Use charts, lists, scales, etc.

Help Clients Think More Rationally o Example Scenario: A 12 -year old boy is feeling frustrated with his stuttering and is becoming withdrawn. o Example Statement: I should talk well/perfectly, but I can’t because of my stuttering. No one understands me when I stutter, so I won’t talk. I am a worthless. o Irrational thought processes: magnification, emotional reasoning, labeling, should statement, mental filter, all or nothing thinking

Help Clients Think More Rationally o Use a true/not true table • • • Feeling TRUE NOT TRUE I stutter I communicate differently People need clarification at times It takes longer for me to express myself My stuttering has nothing to do with my self worth • I can’t talk • People never understand me • I am worthless because I stutter Less Depressed Less Withdrawn Depressed Withdrawn

Help Clients Think More Rationally o Write a list, use a graphic organizer, chart, etc. to define what it means to be a “good talker” Vocabulary Volume Good talker Content of message Body language Eye contact

Help Clients Make a Plan for Change W Want D Doing now E Evaluate P Plan Based on Choice Therapy, Robert Wubbolding

Help Clients Make a Plan for Change o Clients have a choice: to either change what they want or to change what they are doing o Defining what a client wants but stay realistic o Ask the miracle question • Helps to clarify goals • Gives clients a “mental rehearsal” of what they will be doing to achieve that goal o Hold client accountable to the plan!

“ The Miracle Question “Suppose you go to bed tonight as a person who stutters and while you are sleeping, your stutter is miraculously cured. But, because you were sleeping, you don’t know the miracle happened. When you wake up in the morning, what will you do differently that you will know the miracle took place? ” Based on Solution-Focused Brief Counseling (de Shazer, 1990)

Final thoughts on Counseling o The therapeutic alliance accounts for up to 30% of clinical outcomes, whereas treatment techniques only account for 15% or less. o Feelings are not “wrong, ” they just “are. ” Our goal is to help clients manage feelings in a way that is productive, not destructive.

Counseling References & Resources o o o o o Beilby, J. M. , & Byrnes, M. L. (2012). Acceptance and Commitment Therapy for People Who Stutter. Perspectives in Fluency Disorders, American Speech Language Hearing Association Special Interest Group – Fluency and Fluency Disorders, 22, No 1, 34‐ 46. Beilby, J. M. , Byrnes, M. L. , & Yaruss, J. S. (2012). Acceptance and Commitment Therapy for adults who stutter: Psychosocial adjustment and speech fluency. Journal of Fluency Disorders, 37, 289‐ 299. Campos, L. P. (2001). Introduce yourself to Transactional Analysis: A TA primer. Roseville, CA: Sacramento Institute for Redecision Therapy. de Shazer (1990). How to establish well‐formed goals in solution focused brief therapy (The Solution‐ Focused Brief Therapy Audiotape Series). Milwaukee, WI: Brief Family Therapy Center. Eagan, G. (2007). The skilled helper: A problem management and opportunity development approach to helping (8 th ed. ). Belmont, CA: Thomson. Floyd, J. , Zebrowski, P. M. , & Flamme, G. A. (2007). Stages of change and stuttering: A preliminary view. Journal of Fluency Disorders, 32(2), 95‐ 120. Guitar, B. , Hill, D. , Ramig, P. , Zebrowski, P. (2007). Counseling: Listening to and talking with parents of children who stutter (DVD). Memphis, TN: The Stuttering Foundation. Jacobs, E. & Schimmel, C. (2013). Impact Therapy the courage to counsel. Star City, WV: Impact Therapy Associates. Lambert, M. J. (1992). Implications of outcome research for psychotherapy integration. In J. C. Norcross & M. R. Goldstein (Eds. ), Handbook of psychotherapy integration (pp. 94‐ 129). New York, NY: Basic Books.

Counseling References & Resources o o o o o Luterman, D. M. (1996). Counseling persons with communication disorders (3 rd ed. ). Austin, TX: Pro‐Ed. Luterman, D. M. (2008). Sharpening Counseling Skills DVD). Memphis, TN: The Stuttering Foundation. Mosak, H. H. & Maniacci, M. P. (1998). Tactics in counseling and psychotherapy. Belmont, CA: Thomson. Nicholas, A. & Kelman, E. (2014, November). Therapy briefly: The use of solution-focused brief therapy with clients who stutter. Presentation at the annual convention for the American Speech‐Language‐Hearing Association, Orlando, FL. Prochaska, J. O. , & Norcross, J. C. (2006). Systems of psychotherapy: A transtheoretical analysis (Sixth Edition) Pacific Grove, CA: Brooks‐Cole. Scott, L. A. (2010). Implementing cognitive-behavioral therapy with school-age children (DVD). Memphis, TN: The Stuttering Foundation. Sisskin, V. (2014). Helping children change thoughts and feelings about communication (DVD). Memphis, TN: The Stuttering Foundation. Sklare, G. B. (2014). Brief counseling that works: A solution-focused therapy approach for school counselors and other mental health professionals. Thousand Oaks, CA: Corwin. Turnbull, J. (2000). The transtheroretical model of change: examples from stammering. Counseling Psychology Quarterly, 31, 13‐ 21. Zebrowski, P. M. (2013, November). The role of resilience in stuttering intervention for children. Presentation at the annual convention for the American Speech‐Language‐Hearing Association, Chicago, IL.

Contact us: Craig Coleman: craig. coleman@marshall. edu Mary Weidner: weidnerm@marshall. edu More information: www. stutteringacademy. com