2003 IFA Congress: Montreal, Canada

The Why and How of Parent Groups

Willie Botterill, and Frances Cook
The Michael Palin Centre for Stuttering Children, Finsbury Health Centre, Pine Street, London, ECIR OLP, UK.

SUMMARY

The Michael Palin Centre has been involved in running groups for stuttering children and their parents for many years. This paper will explain why and how groups provide such a powerful environment for parents in helping their child who stutters. We will discuss some of the key processes involved in running an effective psycho-educational group for parents. We will also present a blue print for the organisation and running of a six-session weekly group package, as well as the extended two—week intensive programme. Parent satisfaction measures will also be discussed.

  1. Introduction
Many therapists feel comfortable about running groups for children who stutter but feel less confident about working with groups of parents. This paper will include a theoretical background and provide a rationale for running parent groups alongside the children’s groups. In addition we will discuss the principles that underpin the organisation and running of a successful group as well as the framework for the content of the sessions that has been developed at the Michael Palin Centre (MPC) over many years.

  1. Theoretical background
We share the view of many clinicians and researchers that there is no one unifying theory that will adequately explain the complexity and variability of stuttering. There are however a number of researchers and authors who consider that stuttering is currently best understood as being multifactorial and dynamic in nature (De Nil,l999; Smith, 1999; Smith & Kelly, 1997). There are many factors both intrinsic and extrinsic that affect an individual’s ability to be fluent. These broadly include physiological, linguistic, environmental, and psychological factors (Conture, 2000; Gottwald & Starkweather, 1999; Guitar, 1998).

Our understanding of this theoretical position is that for any child there are a number of factors that play a role in the onset and development of stuttering. Furthermore these factors may alter over time as the child’s developing system matures and the internal and external environments shift and change. Our approach to assessment and therapy therefore needs to take account of as many of these variables as possible as we attempt to understand the individual nature of the child’s problem, and plan appropriate therapeutic interventions.

  1. Why include parents?
In the light of this understanding of the problem, and given that, particularly in the early years, parents have a primary role in organising and influencing the child’s physical, emotional, and linguistic environment, it seems logical and important to involve parents as well as clinicians in the process of discovering the best way to support their child’s fluency development.

There is indeed a growing body of clinicians that involve parents in the treatment of children who stutter as an important component in the maintenance of long term changes in fluency (Conture, 2000; Guitar 1998; Manning, 2001). Rustin et al. (1996) discuss the important role that parents can play in facilitating the development of children’s fluency beyond the confines of the clinic room.

There is no suggestion that parents have played a role in the onset of the problem but that the maintenance or amelioration of stuttering can be significantly affected by what they do and how they do it. Furthermore it is usually the parents who are most worried about the child’s speech when they attend the clinic. They frequently have little or no information that will explain why their child has developed this problem and they want to understand what has happened and more importantly what they can do to support their child effectively at home.

It is our belief that involving parents and children at every stage in the assessment and therapy process provides them with the opportunity to help each other make the cognitive and behavioural changes necessary to manage the stutter successfully.

  1. The advantages of a group
The most important and powerful advantage of a group is the experience of being in a group with other parents who share a common problem. Stuttering only occurs in a small percentage of the population, and a child will often be the only one in the playgroup, nursery or school who stutters. Parents similarly describe feeling isolated and alone. A group provides a unique environment in which participants can offer each other the support and reassurance they need to reduce this sense of isolation and helplessness.

Corey and Corey (2002) talk of the immense power of an effective. group to move people in creative directions, helping them make positive changes in their lives and generate new solutions to common problems.

Luterman (1991) describes what he calls the ‘instillation of hope’ and the observation that group participation often helps the members gather courage to try new ideas. As they see others making positive changes they begin to think that they can too.

The sharing of information between the group members and the therapist is another strength of the group process. There is a pool of life experience within the group to call upon as they explore the issues that concern them and come to a new understanding.

Both Corey and Corey (2002) and Luterman (1991) describe the importance of a strong and cohesive group that can provide a safe place for individuals to share feelings of failure, embarrassment, and shame, which are often associated with stuttering. As these views are expressed there is often a release of the control these feelings have had over the person, a catharsis that can be positively life enhancing. Parents describe feeling ‘liberated’ or being able to ‘step back’ and ‘let go.’

  1. Effective group leadership
The leadership style that we adopt at the MPC is directed by our experience of using a cognitive behavioural framework to guide our practice. As Corey and Corey (2002) state ‘If you operate in a theoretical vacuum and are unable to draw on theory to support your interventions, your groups may not reach a productive stage’ The therapists at the centre have training in Personal Construct Theory‘ and Therapy ( Kelly, 1955a &b) and in Cognitive Behavioural Therapy (Beck, 1995 ). These theories suggest we take into account what participants are thinking, feeling, and doing. They also help us understand the various stages of the group process and decide what to do and say to facilitate a group. We base our interventions on the principles of guided discovery as a way of helping members to work together to identify, explore, challenge, and ultimately make key changes for themselves.

We also take the view that co-leadership of a group has considerable advantages. In this way we learn from each other and the group benefits from the perspective of two leaders and from the interactions between the two. The choice of co-leader does however require some consideration. It is essential that there is mutual respect and trust so they can work co-operatively and without the need to prove themselves. It also requires a good working relationship that is achieved by talking, planning and discussing together before the group meets and then before and after each group session.

Corey and Corey (2002) and Manning (2001, describe and discuss at some length the qualities they feel are essential for a therapist to be an effective group leader. Corey and Corey (2002) state their View that these are highly significant variables influencing the success or failure of a group. They include courage, caring, empathy, openness, self-awareness, and sense of humour, flexibility, presence, warmth, and stamina. However, while these qualities are important, those wishing to lead a group will also need to develop basic counselling skills specific to group situations, these are the essential tools of the trade. These are gained with practice, feedback and experience and include skills such as active listening, reflecting, empathizing, clarifying, facilitating, encouraging, supporting, modelling, and initiating, amongst others.

  1. The stages of assessment and therapy at the MPC
All families are assessed fully and recommendations for therapy made based on the findings of the assessments.

Most families have had some individual therapy prior to inclusion in a group and therefore have some knowledge and experience of what is involved. For those seen at the MPC this would probably be Parent Child Interaction Therapy for the younger children (Rustin et al., 1996) or an adaptation of this for older children that we refer to as Family Interaction Therapy. For many families this type of intervention alone is sufficient; there are however some children Whose difficulties are more persistent and would benefit from a group approach. At this stage they are invited to attend one of the six weekly mini groups. Four groups are held during the year. Many of the families find that this provides all they need and stop at this point. The two—week intensive course is for the families who have no access to group therapy locally and have to travel some distance to the MPC. It is also appropriate for a few families known to the MPC who need the extra time and the intensity available on this type of course.

  1. How groups are organised at the MPC
The group programmes at the MPC are short term and psycho—educational in nature. The group members are well functioning individuals who are meeting together to learn more about stuttering and how to manage it more successfully. All parent groups are run alongside the groups for the children and are designed to work in harmony. The topics covered in one group complement the work carried out in the other.

  1. Pregroup planning
This is an essential part of the process and plays a considerable role in its success. Consideration is given to establishing the aims for the groups, the age range of the children’s group, the numbers of participants, the timing, the setting, the resources, and the staffing. Our aims are broadly to:
  • Increase participants’ knowledge of stuttering, and their understanding of themselves and of others.
  • Help them identify the changes they may want to make, and to provide them with the skills they will need to develop these.
  • Create a safe and accepting environment where group members are encouraged to experiment with new ideas that they can incorporate into their lives.
The age group

This varies depending on the children that are referred but broadly span the ages of 7-14. From the age of 15 upwards we run groups for the young adults without the parents.

The numbers

These will depend largely on the resources available. Our groups comprise between 6 -8 children. We always invite both parents to attend the parent group unless it is a one-parent family, so there may be up to 16 members of these groups.

The timing

This will differ for the two group formats, intensive and non—intensive. The non—intensive groups run for two hours at a time, once a week for six weeks. The intensive group runs for two weeks, every weekday from 10.0am —3.30pm , with a one hour lunch break.

The setting

It is essential to have enough space for the children to be quiet and also to make a noise and run around as they need to. It is important for the parents to have sufficient room for chairs to be arranged in a circle and comfortable enough for them to sit for two hours or they will complain! We have also found it essential to have a room for the team to meet, plan and discuss the sessions and a room for seeing families individually as necessary. Convenient access to refreshments and toilet facilities is necessary. Finally it is important to consider the geographical location with access to public transport.

The resources

These include video tape recorders and TV monitors for feedback, a selection of books and handouts, and a flip chart.

The staffing

It is important to have an experienced and skilled leader for both groups. We routinely have three therapists to run the children’s group and two with the parents’ group. In addition student SLT’s are trained to help us and offer the possibility of working 1-1 with the children.

  1. The beginning stage of the group
It is important to remember when we describe the parent group that there is a group for their children running alongside. Both groups are structured in the same way and they cover the same topics but in different ways and using different time frames. At the beginning of the course, sessions are structured in order to provide reassurance for parents who may feel unsure what is expected of them and are therefore anxious. We aim to help all the members participate in semi structured activities designed to gel the group and begin the process of building trust, co-operation and sharing between group members which increase and develop as the course progresses.

Introductions

In welcoming the parents to the group, we introduce ourselves and give some background information about our qualifications and experience. Basic information is also given to them at this stage regarding timings of the group, and general orientation. In this way we start from the beginning to help members feel safe and cared for. 

Group gelling

Following the introductions, our first exercise involves group members in pairs finding out three things about each other and then bringing this information about their partner back to the whole group. This exercise helps each member speak in the group for the first time with factual information about each other. At the end of this exercise we also invite participants to reflect on the purpose of the activity, and their feelings about speaking for the first time in front of the group. At least one member of the group will admit to feeling anxious and having done so several others will join in and share their feelings of relief that others feel the same way. They then find another partner and find out three things about them and so on, until each member has had the opportunity of talking to all the other members of the group. After this exercise they find it much easier to talk openly in front of the whole group. This is an essential starting place, and paves the way for the next activities.

Group hopes and fears

The importance of establishing achievable group goals at the beginning of the course is emphasised. The parents break into. small groups of perhaps three or four and discuss what they hope to gain from the group sessions as distinct from what they want their child to gain from the group therapy. One member of each small group is elected to act as spokesperson and feed back to the whole group the outcome of their discussions. At the end of this process the group has produced a list of goals they wish to work towards. The leaders can then discuss and negotiate with them a set of achievable and realistic goals.

As well as establishing what they hope to achieve from the group it is very important to know what their fears are too. So we repeat this exercise, mixing up the small groups and asking them to share with each other their fears. A different spokesperson is elected to feed this back to the whole group. By the end of this exercise the group members are already experimenting with disclosing some of their thoughts and feelings in an atmosphere that the leaders keep safe and accepting.

Group rules

This follows easily from the above, as we invite the group to consider the rules by which they would like the group to be governed. It is during this exercise that we can discuss confidentiality and the boundaries of this, time keeping and punctuality, turn taking, listening, accepting etc. The success of the group depends on the establishing of rules that foster and encourage active participation from all members in a safe non—judgemental environment. The group and the leaders work together to construct these rules, which are then posted up as a reminder.

The beginning and ending of each session

It is important to attend to the way sessions are opened and closed as it helps the participants to settle and focus on the group. The first task of each session is to discuss the homework assignments. Parents are divided into small groups to share with each other the things that went well and any problems they encountered and then a spokesperson shares these findings with the whole group. The feedback from the homework often generates a great deal of fruitful discussion between the members as they share their successes and their difficulties. At the end of each session, homework tasks are set to help the parents begin to experiment with some of the ideas that have emerged from the exercises and discussions, in their real environment. The end of the session is also marked by asking each parent in turn to reflect on the session and respond to ‘what did you learn from the group to-day?’ or ‘how was the session for you to—day?’ Closing the session in this way encourages participants to summarise their experience and helps them focus on something to take away from the group.

  1. The middle stage of the group: speech and social communication skills
There are a number of topics, which provide the framework for the remaining sessions. Each topic is preceded by a homework task or an exercise that draws attention to the subject matter. The leaders gather information about the topic from the participants using a brainstorm as a way of encouraging ideas and creativity. The discussions that follow allow the group to assimilate and evaluate their experience, and homework tasks are set before the end of the session to help consolidate their understanding.

There is not the scope within this paper to describe all these exercises in detail however the following brief descriptions are typical and can be applied to the remainder of the topics. It is hard to specify how long it takes to cover these topics as it varies so much from group to group. Generally speaking a two—hour session would include homework feedback, and one or two exercises based around one new topic.

What is stuttering?

The parents break into small groups to share their experience of their children’s stuttering. This begins the process of desensitising them to what the children do when they stutter and the feelings that accompany them. These are then shared with the whole group. The group is also introduced to the concept of the vicious circle and the role that thoughts and feelings play in influencing a person’s physical state and behaviour. The group is invited to explore how this fits with what they have observed about their own lives and in relation to stuttering.

What causes stuttering?

They then break again into small groups to share their understanding of what they think caused their child to stutter. This may not have any basis in fact and allows them to talk through any ideas they may have. The discussion that follows in the whole group gives the opportunity to dispel the myths that surround stuttering and presents some of the facts. A fact sheet is made available to the parents to support this.

What skills do we need to be good communicators?

  1. We begin each topic with an exercise designed to raise the parent’s awareness in some way. For this topic, at the end of the previous session we set a homework task where we invite them to observe two people communicating and note two things they do well and two things they do not do well in terms of their skills.
  2. In the next session the parents are encouraged to brainstorm as many ideas as they can think of around the topic. In this case the topic is ‘what skills do we need to be good communicators’. Each member in turn is asked to contribute an idea, after which it is opened to everyone to continue until there are no more. We ensure that during this exercise we also help them to elicit key topics, which are covered during the following sessions.
  3. They are then asked to consider the purpose of the exercise, and its relevance to them and to their stuttering child.
  4. Finally we ask them to consider one communication skill they feel they do well and one they think they would like to improve on.
We work through selected topics for the six—week mini group, or all of the exercises for the two- week intensive course. The topics are covered sequentially, starting with observation and looking, through listening, turn taking, confidence building, problem solving, and negotiation. Each Skill leads to the next working from the simple skills to the more complex. Normal speech production, the mechanics of stuttering, desensitisation, voluntary stuttering, easy stuttering, and speech techniques are also introduced as the children work on these but covered in much less detail.

It is the role of the co leaders to facilitate the process of self-discovery that we have described above. The hallmark of these groups is in the parents’ ability to find solutions to the issues they raise. The leaders by modelling their trust in the parents’ ability to make changes independently, the leaders demonstrate how to allow children to take responsibility for their own stuttering.

  1. The ending of the group
It is important to prepare parents for the ending of the course and the feelings of loss that are likely to accompany it. Time is given to remind the group of the likelihood of relapse and the difficulties of maintaining changes. They also discuss in small groups how they will manage difficulties at home and at school as they occur. The parents’ workbook provides reminders of the topics and activities. A timetable is set for follow up sessions; the first is usually six weeks after the course and at three—month intervals for one year thereafter.

  1. Outcome Measures
We are Committed to the use of outcome measurement and routinely collect data from the families that attend the centre in order to inform and evaluate our therapy programmes. This involves using a range of assessments that measure the cognitive, behavioural and social aspects of the problem. However as far as these authors are aware there are no validated and reliable parent satisfaction measures for use with parent groups of this kind.

Parent rating scales developed at the MPC are routinely completed pre and post course. These are clinical outcome measures and are not yet sufficiently robust to be used in treatment outcome research. We are in the process of developing appropriate assessment tools to be used in prospective research.

References
Beck, J .S. (1995) Cognitive Therapy : Basics and beyond. New York: The Guildford Press.

Corey, M. S. & Corey, G. (2002). Groups, process and practice (6”‘ Ed.) Pacific Group, CA: Brooks /Cole Wadsworth Group

Conture, E.G. (2000) Stuttering (3"‘ Ed.) Needham Heights, MA: Allyn & Bacon.

De Nil, L.F. (1999). Stuttering: a neurophysiological perspective. In N.B. Ratner & E.C.Healey (Eds.), Stuttering research and practice: Bridging the gap (pp. 85-102). Mahwah,NJ: Lawrence Erlbaum.

Gottwald, S.R. & Starkweather, C.W. (1999). Stuttering prevention and early intervention: A multi- process approach. In M. Onslow and A. Packman (Eds.), The handbook of early stuttering intervention (pp. 53-82).San Diego, CA: Singular Publishing Company.

Guitar. B., (1998) Stuttering: An integrated approach to its nature and treatment. (2nd Ed.). Baltimore:Williams and Wilkins.

Kelly, G. A., '(1955a) The psychology of personal constructs Vol. 1 New York: Norton

Kelly, G. A., (1955b) The psychology of personal constructs Vol. 2 New York: Norton

Luterrnan. D. M. (1991) Counselling the communicatively disordered and their families (2nd Ed) Austin, TX:Pro-Ed.

Manning, W. H. (2001). Clinical decision making in fluency disorders (2nd Ed) . San Diego, CA: Singular Publishing.

Rustin, L. Botterill, W. & Kelman, E. (1996). Assessment and therapy for young dysfluent children: Family interaction. London: Whurr Publishers.

Smith, A.(1999). A unified approach to a multi factorial, dynamic disorder. In N.B. Ratner and E.C. Healey (Eds.), Stuttering research and practice: Bridging the gap (pp. 27-45). Mahwah, NJ: Lawrence Erlbaum.

Smith, A., & Kelly, E., ( 1997). Stuttering: A dynamic multifactorial model. In R.F. Curlee and

G.M.Siegel (Eds.) Nature and treatment of stuttering: New directions (2““ ed.). Boston: Allyn & Bacon. ' 84

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