2003 IFA Congress: Montreal, Canada

An Integrated Care System for People Who Stutter

Meina Voors1 and Durdana Putker2
1Centrum Voor Stottertherapie Bloemerzdaal, Donkerelaan 64 2061JP Bloemendaal, the Netherlands
2Stottercentrum Zwolle, Huzjgensstraat Ia 8023 AG Zwolle, the Netherlands

SUMMARY

A group of speech specialists in the Netherlands have been developing a new system for treating stuttering, where a network of therapists can enroll their patients in different modules of therapy. Cooperation between speech therapists has resulted in an Integrated Care System for stutterers, where individual and group therapies form an ongoing, long- term treatment.

  1. Introduction
In 1994 a group of stuttering specialists in the Netherlands formed an association called the Vereniging Stottercentra Nederland-VSN (Association of Stutter Centres, the Netherlands.) The aim of this association is to improve current stuttering treatments, to coach general speech therapists in giving a second opinion (at the request of a SLP or physician) and to develop innovative therapies for stutterers. The centres allow stuttering treatment to be both logistically and cost effective for their clients.

  1. “Made-to-Measure” Therapy
Stuttering treatment in the Netherlands focuses on a dual approach of stuttering modification and fluency shaping. Current treatment methods are influenced by the writings of Peters and Guitar (1993), particularly their integrated approach, and their methods of acceptable stuttering and controlled fluency therapy. Most therapy is provided in an individual therapy setting, although some places offer group therapy. With the belief that a combination of both individual and group therapy will achieve more effective results, a workgroup of the VSN developed an Integrated Care System (ICS) for stutterers.

  1. Individual and Group Modules
Several researchers and writers (e. g. Roodvoets. 1991; Van Riper 1973; Yalom, 1995) write that certain parts of therapy are more effective in individual settings, including motivation, identification desensitisation and, the first part of stutter modification. Conversely, other elements of therapy have been proven more effective in group settings, including transfer, attitude-change, fluency training, consolidation, and the strengthening of self-esteem (Landsheer, 1990; Leahy. & Watanabe, 1997; Ringrose, 1992; Roodvoets, 1991.)

With a grant from’het Prins Bernhard Fonds’, a Dutch fund for cultural and social activities, our association transformed existing group therapies into a more modernized method. In this new format, intensive group therapies with various goals were designed to treat stuttering. These groups included fear reduction for adults, an adolescent group for youth between 12 and 18 years old, a parent-child group for school-aged children and with a grant from Nationale Kollekte Geestelijk Gehandicapten, two groups for people with special needs.

  1. Case Management
Similar to alcohol and drug addiction, it can be difficult for a person who stutters to find an adequate form of therapy. Therefore, ICS appoints a case manager who helps the client in to making a therapy plan, coaching the different parts of therapy, and is responsible for evaluations and follow- up care.

The case management system has four features: individual therapy, evaluation, group therapy and second evaluation.
  • The first step is a diagnostic phase, in which all methods of existing diagnostic instruments are used .
  • The case manager then decides (with the client or the parents) if the patient should be enrolled in the ICS, or needs a different method of treatment
  • If ICS is selected, individual therapy is then organized close to the patient’s home.
  • During this initial individual therapy, the case manager conducts an evaluation where new therapy goals are set. L
  • Following this individual therapy and assessment, group therapy is then conducted in the most appropriate locale.
  1. Evaluations
In order for our association to be transparent to both patients and insurance providers1, indication checklists for each type of group therapy were developed. These checklists corresponds with the National Registration System for speech therapists in the Netherlands (ICDH codes NVLF 1993, WHO 1980.) The checklists enable a therapist to determine which type of group is most suitable for their client based on a set list of conditions, which may include age restrictions, medical diagnosis and personal characteristics. In addition, evaluation questionnaires were developed to indicate the results of the group therapies for each client.

In these questionnaires, the satisfaction of the client with both his/her speech performance as well general communication skills are measured through satisfaction indicators. The questionnaires are repeated several times after the completion of group therapy, with clients assessed for at least two years after treatment. The outcomes of such evaluations have thus far been positive, though the number of clients enrolled in the group therapies until now are small, at around 90.

Furthermore, the coaching and educational services provided to general speech therapists are evaluated through anonymous questionnaires. The results of these evaluations have also been positive. Approximately 70 questionnaires have been returned which assessed coaching, and several hundred have been returned which evaluated education.

  1. Description of different modules
Intensive therapy group for fear reduction The intensive training group for fear reduction works towards decreasing fear, tension and stress related to stuttering. It consists of a seven-day training spread over a period of 4 months:
  • 1 day training focused on the individual goals of the patient
  • 3 day training in a special institute with haptonomic, bioenergetic, creative and speech therapists
  • 2 day training focused on stuttering and daily life
  • 1 day training utilized as an evaluation day to review personal aims and discuss the future
During periods in between therapy, group members work with each other to achieve their individual goals.

Intensive therapy group for fluency enhancing techniques

This group works towards maintaining and stabilizing fluent speech by using different fluency techniques. For each client, two appropriate techniques are determined (Cooper 1993, Dahm 1997).

It consists of seven sessions spread over two consecutive days, followed by a one-day session three weeks later. Intensive coaching by a SLP and former group member is provided throughout the treatment, as well as after its conclusion.

Intensive therapy group for adolescents

Adolescents work with their speech in this group to maximize his/ her development into a communicative self-controlling person.

It consists of two training consecutive days in which self-esteem and courage are important themes. After two weeks and five weeks respectively, a one-day training is held where the youth prepare an instructional day for their parents and other persons interested. This is followed by a half-day conclusion.

Parent-Child therapy group

The parent-child group aims to improve Communication skills in parents and children. Parents and children work together, and in separate groups. Parents are taught how to support child and are given a good communication model (using principles from “Quality Parenting”, Albert 1987.)

Children learn to reduce fear and tension around their stuttering, and are assisted in developing a more communicative way of stuttering.

Groups for people with cognitive challenge (in development)

  1. Additional post- ICS care
Research from the Speech Foundation of America (1982) has shown that some stutterers benefit from regular contact after the conclusion of their therapy, especially when contact is longer than a one-year period. An extension of the relationship between the therapist and their client helps to prevent both a relapse as well as “therapy shopping”.

  1. Outcomes
Examples of the questionnaires used and some preliminary outcomes for adults and adolescents are provided in the Appendixes.

  1. Conclusion
The Integrated Care System strives to provide a care system for stuttering people which has easy access, a transparent coherence between the different phases of therapy, and can be adapted to the wishes and possibilities of the individual client. The client is responsible for his/her part of the therapy process, is treated in a respectful way and can count on his/her case manager at all times.

The case manager provides open communication between the client and the different therapists in the ICS.

As all therapies are preferably organized as close to the patient’s home as possible, cooperation with general and specialized speech therapists in the Netherlands is vital. Since any care system needs continuous attention and monitoring, the therapists are open for discussion and are willing to integrate new insights to improve treatment.

1Insurance companies in the Netherlands demand healthcare providers to be as transparent in their treatment as possible, including diagnosis, improvement and evaluation

References
Albert, L. & Popkin, M. ( 1987) Quality Parenting Random House.

C.B.O. en N.V.L.F. (1999). Lis registratie.Gouda. Kwaliteitsinstituut voor de gezondheidszorg

Cooper, E.B. (1985). Personalized fluency control therapy (revised). Allen-TX.

Covey (1995) De zeven eigenschappen van efiectief leiderschap. Contact, Amsterdam

Craig, A. (1998). Relapse following treatment for stuttering: a critical review and correlative data. Journal of Fluency Disorders, 23, 1-30.

Dahm B. (1997) Generating fluent speech. Eau Claire: Thinking Publications.

Frattali, C.M. (1998) Outcomes measurement: Definitions, dimensions perspectives. New York: Thieme.

Janssen, P. (1985) Gedragstherapie bij stotteren. Utrecht.

Landsheer, J .A.. (1990) Handboek gedragstherapieC 13-2.

Leahy, M.M. & Watanabe Y. (1997) Discourse in group therapy for stuttering (IFAproCeedingS San Francisco)

N.V.L.F. i.s.m. Stichting Automatisering Gezondheidszorg (1993). Voorbereiding en ontwikkeling Landelijke Logopedie Registratie (LLR) Projectvoorstel. Gouda/Utrecht.

Ofman, D. (1992) Bezieling en kwaliteit in organisaties. Baarn

Peters, T.J., Guitar, B. (1991) Stuttering, an integrated approach to its nature and treatment. Baltimore, Williams & Wilkins

Peters, H.F.M., Hulstijn, W., & Starkweather, C.W. (1989) Acoustic and physiological reaction time in stutterers and non-stutterers. Journal of Speech and Hearing Research 32, 668 - 680.

Peters,  Hulstijn, W. (1987) Speech motor dynamics in stuttering. New York.

Riley, J". (1993) Subjective stuttering measurement (experimental)

Van Riper, C. (1987 ) Speech correction. New Jersey

Roodvoets J .M. (1991) Stottertherapie met een menselijk gezicht Amersfoort. Acco

Seagal, S., Home, D. (1998) Human Dynamics, .Scriptum Lanno

Speech Foundation of America( Perkins,Sheehan, Versteegh, Williams(1982) Stuttering therapy: transfer and maintenance. Memphis.

WHO (1980) International Classification of Impairments Disabilities and Handicaps.

Yaruss S. (1998 ) Describing the consequences of disorders: Stuttering and the International Classification of Impairments, Disabilities and Handicaps. Journal of Speech, Language and Hearing Research, 41, 249 - 257.’

Yaruss S. & Quesal, R. (2002) Research based stuttering therapy revisited. Perspectives on Fluency and Fluency Disorders, 12, 2.

Yalom, I.D. (1981) Groepspsychotherapie in theorie en praktijk. Deventer, van Lochum Slaterus B.V.

Appendix 1: Partial Data

AIC_a1.png

Appendix 2: Example of Questionaire

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Appendix 3: Example of Condition List

AIC_a3.png

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