John Wade1, J. Scott Yaruss2, Lee Reeves3, And Nina Reardon4
1University of Kansas, Counseling and Psychological Services, 2100 Watkins Health Center, Lawrence, KS 66049 USA
2University of Pittsburgh, 4035’ Forbes Tower; Pittsburgh, PA 15260 USA
3National Stuttering Association, 3207 Independence Pkwy, Plano, TX 75075 USA
4Private Practice, 2602 Deer Court, Ottawa, IL 61350 USA
The purpose of this panel discussion was to consider the importance of collaboration between and among professionals from different fields and with different backgrounds in the treatment and research of stuttering. There are many reasons that collaboration is useful and important. This manuscript summarizes and highlights some of the ways collaboration can enhance clinical practice in stuttering and to suggest ways clinicians can collaborate with other professionals in their attempts to improve the lives of people who stutter.
- The Need for Collaboration
It is no understatement to say that treating stuttering is a complicated task. This is particularly true for those therapy approaches that involve a broad-based set of treatment goals, including not only changes to the observable characteristics of speech, but also changes in a speaker’s affective, behavioral, and cognitive reactions toward speaking and stuttering, the ability to communicate in daily situations, and the impact of stuttering on a speaker’s overall quality of life. Providing such a broad-based treatment requires that clinicians be able to do more than just count disfluencies; they must also be able to talk with clients about difficult topics (such as emotional reactions to stuttering), to problem-solve strategies for reducing the impact of stuttering on communication ability, and to counsel people who stutter and their families about the need to accept stuttering as a part of life. Although there appears to be disagreement among some clinicians about whether such broad-based treatments are necessary, it is still true that many clinicians do utilize such approaches in their treatment (e.g., Conture, 2000; Manning, 2001; Shapiro, 1999).
Some speech-language pathologists (SLPS) have devoted themselves to developing the skill- set necessary to provide this type of broad-based treatment. In the United States, there is a program for recognizing stuttering specialists. As required by the procedures for acquiring stuttering specialty recognition (detailed at http://www.stutteringspecialists.org), many specialists have already learned to address stuttering from multiple perspectives, using various strategies and techniques, and developing individualized treatment approaches for each client with whom they work. Unfortunately, these specialists are presently few and far between - there are only approximately 275 board recognized stuttering specialists in the USA, out of a total of about 90,000 certified speech-language pathologists (a total of only about 0.3 percent). Evidently, even these well-prepared clinicians find that they sometimes need to collaborate with others who have more expertise in certain aspects of treatment than they do. Of course, they regularly collaborate with other stuttering specialists (as is seen in the discussions on stuttering list servers and in the interchange seen at professional and support group meetings), but discussions in these and other forums reveal that specialists also seem to be willing to consult with others (such as medical doctors, psychologists, teachers and other educators), as well as members of the consumer community (e.g., support groups) in improving their ability to help people who stutter. Although there are, at present, no data to demonstrate the degree to which these interactions occur, for may stuttering specialists, collaboration simply seems to be a part of their commitment to providing the best treatment possible for their clients who stutter.
Given the complexity of stuttering, such collaboration becomes even more important for those clinicians who do not have the opportunity to specialize in stuttering. As the scope of practice for SLPs has increased over the years, the amount of attention generalist clinicians can devote to developing their ability to treat stuttering has obviously diminished. When the field of speech- language pathology was in its infancy, clinicians in the United States could focus on developing their skills for treating people who stutter, as well as people with language, voice, or articulation difficulties (as required by the training standards of the American Speech-Language-Hearing Association). Presently, however, clinicians need to add to this list the ability to treat people with cognitive difficulties, dementia and other age-related disorders, swallowing problems, multiple impairments requiring alternative means of communication, and many other disorder areas. The percentage of time spent on stuttering has decreased to the point where, far from being one of the most common disorder areas addressed by SLPS, it has become one of the least common. Indeed, according to a recent omnibus survey conducted by the American Speech-Language-Hearing Association (ASHA; 2003), stuttering ranked last among all of the 14 disorders surveyed in terms of the average number of clients on clinicians’ caseloads. This means that many clinicians -- even those who those may have an interest in stuttering - simply do not have the opportunity to develop and hone their skills in this area.
The dramatic expansion of the SLP’s scope of practice has also affected the training that student clinicians receive. In the not too distant past, students were required to obtain experience with stuttering both in the classroom and in the therapy room as part of their graduate education. Today, no such training is required. In fact, in a recent study, Yaruss & Quesal (2002) highlighted a significant reduction in the amount of academic and clinical training students receive in ASHA- accredited university training programs in the United States. During a short 3-year period, a significant trend was seen showing: (a) an increase in the percentage of students who are able to complete their graduate education without any academic or clinical training in stuttering, (b) a reduction in the amount of clinical experience required for both diagnosis and treatment of stuttering, (c) a decrease in the percentage of full-time faculty teaching courses on stuttering, and (d) a reduction in the research and clinical experience of the faculty providing education on stuttering. Given these strong trends toward less preparation in the area of fluency disorders for SLP students, it is clear that the situation will only worsen over time.
Of course, clinician discomfort with stuttering is not a new phenomenon. Numerous surveys have documented the fact that many clinicians do not feel that their training in stuttering is adequate (see review in Yaruss, 1999). Many of these surveys were conducted prior to the recent decreases in training highlighted by Yaruss & Quesal (2002). Nevertheless, as the ASHA omnibus survey demonstrates, clinicians continue have continued to try treat stuttering, even while they admit that they are not comfortable with their skills in this area. Therefore, as clinicians become even less well- equipped to help people who stutter, it will be imperative that we change the culture whereby poorly trained SLPs feel that they must treat stuttering - particularly for those clinicians who attempt to treat stuttering by themselves. As a field, we have to help them feel more comfortable collaborating with others (including other SLPs) so they can improve the treatment they provide to people who stutter.
The next sections of this manuscript will address strategies for collaboration in four key areas: psychology, education, and self-help/support. By partnering with individuals from each of these areas, speech-language pathologists can improve their ability to provide broad-based treatment for stuttering and, ultimately, provide better clinical service to people who stutter.
Although most psychologists have limited or no knowledge of stuttering, the field of psychology does have much to offer regarding the treatment of stuttering. Speech therapy focuses on facilitating change -â behaviorally, cognitively, and emotionally. Psychology is essentially the science of facilitating change. Many principles of psychology, such as learning theory, cognitive behavioral therapy, and behaviorism are incorporated into successful speech therapy. The field of speech therapy is also increasingly recognizing the importance of psychological factors to the treatment and research of stuttering. In fact, at the 2002 National Stuttering Association sponsored Stuttering Research Symposium, the vast majority of the discussion within the “Treatment Outcomes” sub-group focused on psychological and quality of life issues.
As mentioned previously, stuttering along with several other communication disorders, is categorized as a mental disorder in the DSM and ICD classification systems. There are likely differing opinions regarding the accuracy of the classification of stuttering within these systems, but the fact that stuttering is listed in the both the mental health and medical classification systems provides a wonderful opportunity that has yet to be fully realized. Professionals (psychologists, social workers, physicians, psychiatrists, etc.) who utilize the DSM or ICD have an ethical obligation to have at least basic knowledge about the disorders within the classification system they utilize. T 0 date, information has not been provided to nearly enough allied professionals, leaving a vacuum. It is apparent that the lack of knowledge among most mental health professionals will not be remedied from within the fields of psychology or medicine. It is incumbent upon speech therapists and speech therapy researchers to fill the Vacuum and provide accurate information to those professions that impact stuttering. Many avenues exist by which to do this, if we are willing to make the effort. These include collaborating with allied professionals at professional conventions, reviewing and editing articles on stuttering in various professional journals, providing information on stuttering for national licensing exams in psychology and medicine, and providing information on stuttering to authors of textbooks on mental health assessment and diagnosis, to name a few.
Some of the obstacles that teachers often face in dealing with children who stutter in the classroom include a lack of knowledge of the disorder, misperceptions regarding the skills of children who stutter and finally, the variation of the disorders that teachers must learn to manage in today’s classroom environments (e.g., Crowe & Walton, 1981; Guzetta et al., 1998; Lass et al., 1992; Ruscello et al., l994; Yeakle & Cooper, 1986) . Most of these obstacles can be overcome through education and support by speech-language pathologists and other professionals involved in a child’s case. It is important to note that education regarding stuttering and stuttering therapy and support for classroom teachers must be ongoing. Teachers will need more than a brochure and a short conference at the beginning of an academic year.
Integrating the classroom teacher into a child’s process of therapy can be seen as an opportunity to create a daily atmosphere that supports the child in many challenging communicative situations. In addition to the information provided by speech-language pathologists, children can often be encouraged to educate their teachers and peers about stuttering. During these many ongoing interactions, teachers can become therapists’ eyes and ears, while providing a child with yet another ally as he learns to deal with stuttering in daily communications.
- Consumer Based Support Organizations
Pediatricians are often the first professionals consulted by parents when concerns about stuttering arise. Unfortunately, physicians in general and pediatricians specifically have little or no training in communication disorders. Parents report that they are most often advised to wait for the child to “outgrow” stuttering. As a result most parents do not seek early intervention by an experienced speech-language pathologist. This is a great disservice both to the child and to the family since there is mounting evidence that early diagnosis and treatment by a knowledgeable SLP may result in resolution of symptoms and prevention of chronic stuttering. While physicians are often the first professional consulted some parents of children who stutter as well as adults who stutter seek advice from other professionals such as teachers or school counselors. Individuals and families may also seek treatment from professionals such as psychologists or psychiatrists. Again, there is limited knowledge about stuttering among these health professionals.
Consumer based self-help/ support organizations have worked for many years to increase awareness and dispel misconceptions and misinformation about stuttering. This has been accomplished through a Variety of avenues such as the production and distribution of informational brochures and other written materials, public service announcements, newspaper articles, and occasionally having a representative or parent speak at professional or civic meetings or schools. In addition the National Stuttering Association has produced a telephone rolodex card to provide a quick reference for physicians, sponsored an informational booth at a national convention for psychiatry, and has established as one of its strategic goals expanded outreach and collaboration with allied professions.
In an attempt to open a dialogue about the future of stuttering research the National Stuttering Association hosted last year the first ever symposium for researchers, clinicians and consumers. The purpose of the symposium was to bring people from a variety of professional disciplines interested in stuttering together to discuss along with consumers the current state of stuttering research and to develop collaborative working relationships for future research. Consumer based organizations are uniquely positioned to facilitate these kinds of collaborative events and many more are necessary for future progress.
American Psychiatric Association (1994). Diagnostic and Statistical Manual of Mental Disorders, (4”â ed.). Washington, DC, American Psychiatric Association.
American Speech-Language-Hearing Association. (2003). 2003 Omnibus Survey Caseload Report: SLP. Rockville, MD: Author.
Bernstein Ratner, N. (1997). Stuttering: A psycholinguistic perspective. In R. Curlee & G. Siegel (Eds.), Nature and treatment of stuttering: New directions (2nd ed.) (pp. 99-127). Boston: Allyn & Bacon.
Bloodstein, O. (1993). Stuttering: The Search for a cause and cure. Needham Heights, MA: Allyn & Bacon.
Bloodstein, O. (1995). A handbook on stuttering (5th ed.). San Diego, CA: Singular Publishing Group. ,
Conture, E.G. (2000). Stuttering (3rd ed.). Needham Heights, MA: Allyn & Bacon.
Crowe, T.A., & Walton, JH. (1981). Teacher attitudes toward stuttering. Journal of Fluency Disorders, 6, 163-174.
Guzetta, M., et al, (November, 1998). Elementary education teachers’ perceptions regarding stuttering: A survey study. A poster session presented at the American Speech-Language- Hearing Association. San Antonio, TX. _
International Stuttering Association Website (http://www.stutterisa.org/isa001.html#mission). (2002).
Lass, N], et al, (1992). Teachers’ perceptions of stutterers. Language Speech, and Hearing Services in the Schools, 23, 78-81.
Manning W.H. (2001). Clinical decision making in fluency disorders. San Diego, CA: Singular Publishing Group.
Ruscello, D.M., Lass, N.J., Schmitt, J .F. & Pannbacker, M.D. (1994). Special educators’ perceptions of stutterers. Journal of Fluency Disorders, 19, 125-132.
Shapiro D.A. (1999). Stuttering intervention: A collaborative journey to fluency freedom. Austin, TX: Pro-Ed. Section 10. Self Help Programs, Service Delivery and Professional Issues 555
Smith, A., & Kelly, E.M. (1997). Stuttering: A dynamic, multifactorial model. In R. Curlee & G. Siegel (Eds.), Nature and treatment of stuttering: New directions (2nd ed.) (pp. 204-217). Needham Heights, MA: Allyn & Bacon.
U.S. Department of Health and Human Services (1991). The International Classification of Diseases, 9”â Revision, Clinical Modification: ICD-9-CM (DHHS Publication No. PHS 91- 1260). Washington, DC, U.S. Department of Health and Human Services, Public Health Service.
Yaruss, J.S. (1998). Describing the consequences of disorders: stuttering and the International Classification of Impairments, Disabilities, and Handicaps. Journal of Speech, Language, and Hearing Research, 49, 249-257.
Yaruss, J .S. (1999). Current status of academic and clinical education in fluency disorders at ASHA- accredited training programs. Journal of Fluency Disorders, 24, 169-184.
Yaruss, J.S., & Quesal, R.W. (2002). Academic and clinical education in fluency disorders: An update. Journal of Fluency Disorders, 27, 43-63.
Yaruss, J.S., Quesal, R.W., & Murphy, W. (2002). National Stuttering Association Members’ opinions about stuttering treatment. Journal of Fluency Disorders, 27, 227-242.
Yaruss, J.S., Quesal, R.W., Reeves, L., Molt, L., Kluetz, B., Caruso, A.J., Lewis, F., & McClure, J .A. (2002) Speech treatment and support group experiences of people who participate in the National Stuttering Association. Journal of Fluency Disorders, 27, 115-135.
Yeakle, M.K. & Cooper, E.B. (1986). Teacher perceptions of stuttering. Journal of Fluency Disorders, 1], 345-359.