2003 IFA Congress: Montreal, Canada

Student Clinician Preferences for (Not) Working With Stuttering

Margaret M. Leah Y1, Calum M. Delaney2, And Kathleen Murphy1
1Clinical Speech & Language Studies, Trinity College Dublin, Ireland.
2School of Health and Social Sciences, University of Wales Institute Cardiff , Western Avenue, Cardiff, CF5 2YB, United Kingdom

SUMMARY

Student clinicians in their 3rd and 4th years of study in Ireland and Wales participated in a study of preferences for working with client groups, including people who stutter. Influencing factors for preferences relating to personal and clinical experience of stuttering, subjective evaluation of competencies, and perceptions of stuttering were examined. Results indicated that clinical and non-clinical experiences were not good predictors of students’ preferences for working with people who stutter, and perceptions of competence were similar to those for other client groups. Perceptions of stuttering suggested that it was viewed differently to other client groups. Implications of these findings were discussed.

  1. Introduction
Working within the field of speech and language disabilities provides a wide variety of choice for practitioners to develop experience and expertise. There are several possible reasons why people choose to enter the field in the first instance, with some making the choice because of an interest in the area that relates to family or personal experiences, others knowing little about communication disabilities will have been motivated to ‘work with people in a caring capacity’, and still others will have an academic interest in communication or linguistics, which has generated the interest in the field of disabilities. Several other possibilities exist but whatever the reason, along with personal history, motivation and interests, it is likely that the learning_ experiences of student speech and language therapists will influence choices for working with different client groups (Manning, 1996; Shapiro, 1999).

The literature on clinician attitudes to working with stuttering indicates concern about educational preparedness in terms of academic and clinical training over at least three decades (e. g., Cooper & Cooper, 1985; 1992; 1996; Cooper & Rustin, 1985; Curlee, 1985; Mallard et al., 1988; St. Louis & Lass, 1980; Wingate, 1971; Van Riper, 1973). Cooper and Cooper (1996) compared clinician attitudes over an 18-year period (1973-1991) and although some shifts in attitudes in a more-positive direction were noted, unsubstantiated beliefs regarding personality of people who stutter, their parents, and the efficacy of intervention were still held, indicating educative ineffectiveness with regard to such central issues of concern in stuttering. A similar comparison of changes in clinicians’ attitudes in the UK between 1985 and 2000 showed increased positive trends towards early intervention and a reduction of negative attitudes to people who stutter. However it was evident in this study that clinicians still regarded the treatment of stuttering in adults as ‘complex’, and doubted their ability as clinicians in this area (Crichton-Smith, Wright, & Stackhouse, 2003). Other studies have indicated that limited academic and clinical education relate to the preponderances of clinician negativity to working with stuttering (e.g., Brisk, Healey, & Hux, 1997; St. Louis & Durrenberger, 1993). In a wide-ranging survey of ASHA-registered clinicians with regard to their most and least preferred disorder to serve, and the reasons why, St Louis and Durrenberger (1993) found that the disorders for which clinicians have least positive feelings include stuttering and cluttering, with stuttering in adults the least preferred of all disorders. Reasons most frequently given by clinicians for preferences relate to personal satisfaction and professional growth; reasons for non-preferences are lack of training and experience, followed by negative feelings and lack of success.

The authors of this research study are involved in student SLT professional education in university centres in the UK and in Ireland. Leahy (l994) and Delaney (2000) have conducted separate studies with student clinicians with the objective of modifying the pervasive negative stereotype of ‘the stutterer’ held by students (Horsley & FitzGibbon, 1997), and in turn to improve the situation for clients in therapy. Delaney (2000) found that relevant clinical experience of involvement in an attitude modification therapy group for adults who stutter served to improve student attitudes. This finding was in line with Horsley and FitzGibbon’s (1997) finding that students in the later years of education had more positive attitudes to people who stutter, indicating that increased experience had positive influences. Leahy’s (1994) study on the other hand found that clinical experience influenced students variably, with positive, negative, and no changes in attitudes of a group of students as a result of involvement in adult group fluency therapy.

Despite the evident negative attitudes towards stuttering that students may hold, there is evidence too that some students are enthusiastic about working in stuttering, and clearly motivated to do research and practice in fluency and stuttering. Therefore, we decided to change the focus of the investigation away from stereotyping, and towards discovering student preferences for working with particular client groups, and to examine some factors possibly related to such choices.

  1. Method
The principle objectives in the study were to identify those students indicating a definite interest in working in stuttering, and those who specified a definite non-preference for working in stuttering; to explore the factors that seem to influence their choices in terms of clinical and non- clinical experiences, and in terms of their subjectively perceived competencies; and to explore the factors influencing their choices for preferences and non-preferences for working in stuttering. Participants were assured of confidentiality in completing the questionnaire, and those who agreed to participate in further investigative work were assured of the option to discontinue with the study at any stage should they have wished.

Students in their 3rd and 4th  years of study in two recognised university schools of education for speech and language therapists participated on a voluntary basis in the study. There was a total of 29 3rd year students (18 from Dublin, 11 from Cardiff), and a total of 38 4th  year students (23 from Dublin, 15 from Cardiff). Students were requested to complete a 4-page questionnaire that specified 25 major client groups, and allowed for others to be mentioned. The first two pages requested students to indicate clinical and personal non-clinical experience with the client groups. The second part requested students to indicate three client groups they would prefer to work with and three that they would prefer not to work with. For each of these six groups they were asked to rate themselves in terms of their perceived competencies (Williamson, 2001). Students were unaware that the issue of stuttering was of particular interest for this part of the study.

Means of the ratings of the three preferences for working with certain client groups, and 3 preferences against working with certain client groups, were obtained for each of the seven competencies measured for all the students. These competency rating scores for preferred and non- preferred client groups provided a comparison for the ratings of competencies by those students who expressed preferences for and against working with children or adults who stuttered.

Following upon this, three Cardiff students who had indicated a non-preference for working with stuttering were asked to participate in a semi-structured interview regarding self and stuttering; and to write a character sketch of ‘me as a clinician with people who stutter’. The interviews were transcribed, and these and the character sketches were analysed by the first two authors for the themes that emerged. Those themes that were raised by more than one student and more than once by at least one student were identified.

  1. Results
One student was eliminated from the analysis as she expressed a preference for both working and not working with adult stutterers.

a.) Experience and Working preferences in relation to stuttering

Taking into account all 3 preferences for and 3 preferences against working with certain client groups expressed by the students, 6% of these showed a preference for working with child and adult stutterers. This was comparable to many of the client groups, with the exception of acquired and developmental language and child phonology, which together accounted for 35% of the preferences expressed. The other client group which showed a high percentage of preferences was child learning disability (10%). 11.5% of the preferences for not working with a particular client group were those relating to adult stuttering. 4.5% related to child stuttering, which was similar to many other client groups. The only other client groups approaching the adult stuttering non-preference were child learning disability (9%), adult learning disability (8.5%) and adult ENT (8%).

The types of clinical and non-clinical experience of students and preferences for working or not working with people who stutter are presented in Table 1. One student (a 4”â  year with clinical experience of stuttering) expressed a preference for working with adult stutterers and not working with child stutterers, and so she is entered twice on the table. The numbers of students preferring to work with stutterers are similar for child and adult. All of these students reported experience of stutterers, and the majority were in their fourth year of study. '

Of those students expressing a preference for not working with stutterers, the majority targeted their non-preference at adult stutterers. The majority of these students reported experience of stutterers and the distribution across the two years of study was similar. Most of the students expressing no preference for or against working with people who stutter also reported experience of stutterers. In all three cases the students’ experience predominantly included clinical experience.

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Table 1. Experience and working preferences in relation to stuttering

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Figure 1.  Perceptions of competence and working preferences

The comparison of perceived competencies by students expressing preferences for working with stutterers, and those expressing preferences for not working with stutterers, are shown in Fig. 1. Also shown are the mean competency rating scores for all preferred and non-preferred client groups. For all client groups there was a difference between perceived competencies for preferred and non- preferred client groups, and there was a similar pattern in relation to preferences for working with, or not working with, people who stutter. The discrepancies were greatest in relation to perceived skill competence, and knowledge, decision-making and effectiveness. Perceptions of empathy were more similar, and to a lesser extent perceptions of being a safe practitioner. _ With respect to those students expressing a preference for working with people who stutter, those with a preference for working with adults rated their perceptions of competence generally higher than those with a preference for working with children, and some of these ratings were higher than the mean competency rating scores for all client groups. This suggested that those students who preferred to work with adults who stutter viewed their competencies positively. In contrast to this, those students who expressed a preference for working with children who stutter Viewed their competence marginally less favourably, particularly in relation to how safe they felt as practitioners. In general though these ratings were not markedly different to the mean competency rating scores for all client groups.

With respect to the students who expressed a preference for not working with adults who stutter, their ratings of their competencies were very similar to the mean competency rating scores for non-preferred client groups. Those who expressed a preference for not working with children rated their competencies with this client group more favourably, closer to the competency ratings of students with preferences for working with children who stutter. The greatest differences in the ratings for most of the competencies were between the ratings by students expressing a preference for working, and for not working, with adults who stutter.

c.) Attitudes and feelings expressed in interviews and character sketches

The perceptions of three students who expressed a preference for not working with stutterers, in terms of their feelings, their perceptions of stuttering and people who stutter and their perceptions of therapy with stutterers, are presented in Table 2.

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Table 2. Themes identified from interviews and character sketches

In terms of feelings, students presented issues relating to fear, ‘being scared’ or’ nervous’, and issues relating to confidence and experience. Perception of people who stutter was described in terms of ‘something unique’ and ‘different to other client groups’. The disorder was viewed as being ‘challenging’, and producing ‘uncertainty’. This made it ‘difficult to understand’ and one student felt that unlike other disorders she ‘didn’t have an instinctive response to it’. It was ‘variable’, linking with ‘unexpected’ and ‘unpredictable’, and that an aspect of the disorder was that it was ‘psychologically more complicated’ and ‘involved psychological components’ that ‘affected Whole lives’. The perception of therapy was that it needed to ‘lack structure’, which was a ‘mark’ of stuttering therapy, and an important component of therapy was needing to establish ‘what was going on’. There was also a perception that one can ‘do damage’, ‘make the stutter worse’, which they felt was a perception acquired from within the profession, and that there was a need for counselling in therapy.

  1. Discussion
This study presents some results that are considered encouraging. The numbers of students that would actively choose to work with stuttering are similar to, or more favourable than, the numbers of those interested in many other client groups. This result implies positive attitudes for these students, which reflect increasing positive attitudes indicated in other studies (e. g., Cooper & Cooper 1996; Crichton-Smith et al., 2003). With respect to students expressing a preference for not working with children who stutter, this is again similar to many other client groups. However, the numbers of students who actively choose not to work with adults who stutter are higher than for other client groups, similar to the findings of St Louis and Durrenberger (1993) and supporting some of the comments made by Lass et al. (1989) and Hulit and Wirtz (1994). The results of the study suggest that experience of stutterers and stuttering (whether clinical, non-clinical or both) is unlikely to predict whether students will express a preference for or against working with people who stutter (or neither). This is in contrast to other findings that indicate that experience is likely to have positive effects (e.g., Brisk et al., 1997; St. Louis & Durrenberger, 1993), or that experience of stuttering might give rise to negative attitudes (Weisel & Spektor, 1998). The interpretation of this apparent contradiction may be that experience may have differential effects, depending on variables such as type of experience and certain characteristics of individuals (Delaney, 2000; 2002). This may also explain the greater number of students in 4th  year choosing to work in the area, as reflected in the study by Horsley and FitzGibbon (1987).

Students’ perceived competence to work with people who stutter varies with their preferences for and against such work in a manner that is similar to preferences for working with other client groups. With respect to working with children who stutter, those students who expressed preferences for and against rated their competencies more similarly than those who expressed preferences for and against working with adults who stutter. This suggests that perceptions of competence may be less of a factor in determining preferences in relation to children as to adults who stutter, and that students who would choose to work with adults who stutter rated their competencies more favourably than those who would work with children.

Some explanation of the differences discussed above that mark preferences in relation to adults who stutter might be gained from the comments made by the students who were interviewed and provided character sketches. The majority of the comments they offered were expressed in relation to adults who stutter, and may help to explain the numbers of students who expressed a preference for not working with this group. Their predominant perception was that stuttering was somehow different to all other disorders, with the possible exception of adult voice disorders, and had unique characteristics. It was perceived as more complex (as found by Crichton-Smith et al., 2003) and less tangible than other disorders, and always came with a psychological overlay which would also have to be addressed in therapy. This carried with it a greater risk of doing harm, and required a greater depth of experience to be able to manage the Variety of components of the disorder that (it was predicted) were likely to be different for every individual. It is possible that the manner in which stuttering is viewed and discussed within the profession, and the way that therapy is practised may have contributed to these impressions.

  1. Conclusion
This paper presents some preliminary findings that may provide useful pointers for further work. Stuttering and therapy with fluency disorders may have unique characteristics. It may be that for this reason that those who choose to work with people who stutter are drawn to them for different reasons to those who choose to work with other client groups. For those who choose not to work with people who stutter it is possible that a part of their attitude lies in a perceived emotional loading accompanying stuttering, the negative stereotype described in many studies. A more careful examination of this loading in those students and clinicians who choose not to work with people who stutter, and its possible effect (or the manner in which it is perceived and dealt with) by those who do choose to work with stutterers, may provide a greater understanding of the perception by students of the nature of stuttering.

References
Brisk, D. J ., Healey, E. C., & Hux, K. A. (1997). Clinicians’ training and confidence associated with treating school-age children who stutter: a national survey. Language, Speech and Hearing services in Schools, 28, 164-176.

Cooper, E. B. & Cooper, C. S. (1985). Clinician attitudes towards stuttering: a decade of change (1973-1983). Journal ofFluency Disorders, 10, 19-23. '

Cooper, E. B. & Cooper, C. S. (1992). Clinician attitudes towards stuttering: Two decades of change.

Paper presented at the ASHA Annual Convention, San Antonio, TX.

Cooper, E. B. & Cooper, C. S. (1996). Clinician attitudes towards stuttering: Two decades of change. Journal of Fluency Disorders, 2], 119-135.

Cooper, E. B. & Rustin, L. (1985). Clinician attitudes towards stuttering in the United States and Great Britain: A cross-cultural study. Journal of Fluency Disorders, 10, 1-17.

Crichton-Smith, 1. Wright, J., & Stackhouse, J. (2003). Attitudes of speech and language therapists towards stammering: 1985 and 2000. International Journal of Language & Communications Disorders, 23, 213-234.

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Delaney, C. M. (2000). Modification of the negative stutterer stereotype. In H.-G. Bosshardt, J .S. Yaruss, &  Peters (Eds.), Fluency Disorders: Theory, Research, Treatment and Self- Help. Proceedings of the Third World Congress of Fluency Disorders in Nyborg, Denmark (pp. 614-619-29). Nijmegen: Nijmegen University Press.

Delaney, C. M. (2002). Stereotypes and stereotyping of people who stutter: A new direction and an alternative rationale. In C. Williams & S. Leitao, (Eds.), Journey from the Centre: Proceedings of the 2002 Speech Pathology Australia National Conference (pp. 105-111), Melbourne: Speech Pathology Australia.

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Hulit, L. M., & Wirtz, L. (1994). The association of attitudes toward stuttering with selected Variables. Journal of Fluency Disorders, 19, 247-267.

Lass, N., Ruscello, D.M., Pannbacker, M.D., Schmitt, J .F. and Everly-Myers, D.S. (1989). Speech- language pathologists’ perceptions of child and adult female and male stutterers. Journal of Fluency Disorders, 14, 127-134.

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Shapiro, D. A.(1999). Stuttering intervention: A collaborative journey to fluency freedom. Austin, TX: Pro-Ed.

St. Louis, K.O. & Lass, NJ. (1980). A survey of communication disorders students attitudes toward stuttering. Journal of the National Student Speech Language Hearing Association, I 0, 88-97.

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