2003 IFA Congress: Montreal, Canada

A Multinational Investigation of Stuttering Intervention: Assumptions, Practices, and Lessons

David A. Sharpiro: Professor, Speech-Language Pathologist
Western Carolina University, Communication Disorders Program, Department of Human Services, Killian 204 Cullowhee, North Carolina 28723 USA

Manon Abbink: (representing Poland and Germany) Speech-Language Pathologist, Stuttering Therapist
Almelo, The Netherlands

Melissa Bortz: Speech-Language Pathologist and Coordinator
Multidisciplinary Clinic of the Hillbrow Community Partnership in Health Personnel Education
Johannesburg, South Africa

Andrea Bruna V.: Speech-Language Pathologist
Private Practice, Santiago, Chile

Frances Cook Principal Speech and Language Therapist, Manager
Michael Palin Centre for Stammering Children, London, England

Peter Dhu: President
Speak Easy Association of Western Australia, Perth, Western Australia

Johanna Einarsdottir: Speech and Language Therapist Private Practice
Taljalfun Reykjavikur; Iceland

Elizabeth Haynes: Speech-Language Pathologist
Institute for Stuttering Treatment and Research, University of Alberta, Edmonton, Alberta, Canada

Sinfree Makoni: Associate Professor Speech-Language Pathologist
Long Island University, Brooklyn, New York USA

Shoko Miyamoto: Speech-Language Pathologist, Doctoral Student
Hiroshima University, Hiroshima, Japan

Lawrence Molt: Chairman, Associate Professor, Speech-Language Pathologist/Audiologist
Auburn University, Auburn, Alabama USA

Nelson Moses (representing Chile): Chairman, Speech-Language Pathologist
Long Island University, Brooklyn, New York USA

Isabella Reichel (representing Russia and Ukraine): Adjunct Professor and Stuttering Specialist
Fluency Renaissance Center, Long Island University, Brooklyn, New York USA

Anne-Marie Simon Assistant Professor, Orthophoniste
Bourg-La Reine, France

Beatriz Biain de Touzet: Professor; Speech-Language Pathologist
Buenos Aires University, Buenos Aires, Argentina

Yvonne Van Zaalen: Speech Therapist, Senior Stuttering Therapist
Praktyk voor Logopedie en Stottertherapie, Amersfoort, The Netherlands

Margaret Marks Wahlhaus: Speech Pathologist and Audiologist, Honorary Research Associate
Australian Stuttering Research Center; University of Sydney, Australia


The specific purposes of this research were to determine the assumptions, methods, and ultimate lessons learned and purposes served by clinicians who treat people who stutter in diverse nations across the world, and to make comparisons within and across countries and cultures. Seventeen clinician-researchers representing 14 countries across 6 continents each distributed a 10-item survey to an intended sample of 25 clinicians in their own country Who treat people who stutter. The results, both quantitative and qualitative, reveal a commonality of purpose among multinational service providers, the importance of working together and communicating across international borders, and a window into the world as a global classroom.

  1. Introduction and Procedures
This paper represents a professional commitment by 17 clinician-researchers representing 14 countries across 6 continents to study the clinical methods for stuttering intervention being used in their country, the diverse factors and assumptions that impact the design of those methods, and the ultimate purposes and lessons being achieved (i.e., beyond speech fluency). Although there is a growing literature calling for empirical analysis of intervention procedures across countries and cultures (Pickering, 1994, 1995; Pickering & McAllister, 1997, 1998, 2000), the existing literature implementing this recommendation in the area of stuttering is scant at best. The Proceedings from the three previous World Congresses on Fluency Disorders sponsored by the International Fluency Association are replete with topics of both depth and breath that are relevant to fluency and fluency disorders. Similarly, other venues for professional publication address theoretical, empirical, clinical, and cultural approaches to fluency disorders. However, despite the many topics addressed and mindful of their significant contribution to our understanding the discipline of fluency disorders, direct comparison across national borders is virtually nonexistent.

As world crises become a daily occurrence, demonstrating a commitment to working together and communicating across international borders has never been more important. Doing so creates a context that facilitates shifts of perspective, the hallmark of communication (Shapiro, 1999; Shapiro & Moses, 1989). Such communication and open sharing enable clinicians from diverse countries to learn from and grow with each other, in a safe and nurturing environment. In this way, the profession of speech-language pathology becomes a microcosm of the world and the discipline of stuttering intervention, indeed this World Congress, presents an ideal opportunity for building bridges toward global understanding.

A presentation at the third World Congress (Shapiro et al., 2000), upon which the present investigation is based, established three anchoring assumptions. Those assumptions are relevant to the present presentation as well. Specifically, “the world has become a global classroom” (p. 505), “Clinicians have an obligation to examine the validity of their clinical methods” (p. 506), and “Learning is a lifelong process and one avenue to learning is dialogue” (p. 506). [See also Shapiro et al., 2001.]

For the present investigation, each participant distributed an open-ended, 10-item survey to an intended sample of 25 clinicians in their country who work with people who stutter (see Appendix; in most cases, the survey was translated by the co-author before distribution). The survey was revised as a result of pilot investigation by the first author while on a research fellowship in Japan during the summer of 2001. All procedures were approved by the Institutional Review Board at Western Carolina University. In the following sections, the presenters will summarize the responses received from the clinicians sampled within their own country, briefly addressing six questions:

  1. What are the demographics of the clinicians you sampled (e.g., professional and work setting, professional preparation, and professional experience; composite response from survey questions 1, 2, 3)?
  2. What are the prevailing definitions and perceived causes of stuttering that were provided by the clinicians sampled (survey questions 4, 5)? How do these causes compare to those held by the general public in your country?
  3. How do the clinicians in your country conduct intervention with people who stutter (survey question 6)?
  4. What factors influence what the clinicians do and how they design their intervention methods (survey question 7)? In other words, ymi do clinicians do what they do? How are the intervention methods influenced by cultural, political, social, economic, geographic, academic, and other factors?
  5. What obstacles or issues do Clinicians experience when assessing and treating clients who stutter and their families (survey questions 9, 10)?
  6. What do clinicians seek to teach (beyond speech fluency) by virtue of what they do professionally (survey question 8)? Often, clinicians’ efforts are directed toward 126 Theory, research and therapy in fluency disorders influencing the affective, behavioral, and cognitive factors related to speech fluency. This question seeks a broader perspective. For example, one might think that our work demonstrates that improved communication is possible, thereby contributing toward global understanding and world peace.
  1. Results

Argentina (B. Touzet)
Twenty clinicians (12 speech therapists, with 3 years of university study; 8 master speech pathologists, with 5 years of university study) in Buenos Aires completed the survey. Work settings included public hospitals (11), private consultation (3), public and private schools (4), and private institutions (4) (i.e., 2 work in both the public hospital and private consultation). Professional experience included less than 3 years (5), from 4 to 10 years (11), and more than 11 years (4). Over the last 5 years, the clinicians worked with clients who stutter including preschool children (70), school- age children (250), adolescents (30), and adults (12). Predominant causal explanations for stuttering were genetic-hereditary with environmental influence. Treatment methods for preschoolers included family-based interaction and communication modification through slow speech and syllable stretch; for school-age children included attitude modification, tension reduction, interaction with family members and teachers, and slow language modeling with soft onsets and pauses; for adolescents included cognitive reorganization, gentle speech production, and self-help and group support; for adults included preventing avoidance, stuttering openly without fear, attitude modification, and self- help and group support. Factors influencing intervention included geographical distance rendering treatment less accessible, economic affordability, absenteeism causing discontinuity in treatment, misinformation in the media (i.e., promoting social taboos) and schools (i.e., encouraging and accepting jokes, thus minimizing impact of stuttering) and among pediatricians (e.g., stuttering will go away), shortage of speech therapists and self-help groups, and absence of training in stuttering intervention. Other critical issues included family resistance to treatment, general resistance to change, and silence and negativity. Notwithstanding these challenging issues, ultimate objectives included general communication improvement, self-acceptance, easier speech, and integration of people who stutter into society.

Australia (P. Dhu)
A total of 22 clinicians were surveyed from the State of West Australia (1 of 6 Australian states). All are speech pathologists with an Australian degree in speech pathology (18 have Bachelor’s degrees; 4 have Master’s degrees). Work settings included private practice (4) and the Government Health Sector (18). Professional experience in treating people who stutter included less than 1 year (1), from 1 to 5 years (9), 5 to 10 years (5), 10 to 20 years (6), and more than 20 years (2). The ages of clients treated ranged from 2 to 80 years; most clinicians (ll) primarily treat children, fewer (6) treat both children and adults, and fewest (4) treat adults only (1 clinician did not specify the age of clients treated). Most clinicians referred to stuttering as a disorder, disruption, interruption, or breakdown in the forward flow of speech; 13 referred to blocks, prolongations, and repetitions in their definition. Causal factors included genetic (10), neurological (6), motor or physical (6), variable (6), and unknown (4) (i.e., several clinicians noted more than one causal interpretation; therefore the total does not equal 22). Nearly all practitioners treating children use the Lidcombe program. All treating adolescents or adults use smooth speech or prolonged speech (i.e., fluency shaping); time out and anxiety management was noted by 1 practitioner. The major factor influencing practitioners in Western Australia is empirical support, or evidence-based practice. Parent involvement for children and training of parents was viewed as critical (i.e., a key component of Lidcombe), thus continuing the treatment in the home between scheduled treatment sessions on a daily basis. Four practitioners noted the importance of developing therapy that is tailored to meet the client’s individual needs. Obstacles that impact practitioners treating people who stutter included problems with parent involvement or motivation (13), shortage of time and resources to meet the demands of heavy caseloads (4), misinformation causing misunderstanding that is perpetuated by the media (5), and clients deserving a “quick fix”  solution (3). Yet, while the ultimate objective is enhanced fluency or stutter-free speech (5), most practitioners strive toward holistic objectives including improved general communication, non-verbal skills, self-esteem and self-confidence, and otherwise reaching one’s potential in life and in one’s career. Eliminating stuttering was noted most often as the ultimate objective when treating children; more holistic objectives were noted most often when treating adults.

Canada (E. Haynes)
Thirty two surveys were completed from throughout Canada (British Columbia -2, Alber:a- 10, Yukon Territory-1, Saskatchewan-2, Ontario-6, New Brunswick-4, Nova Scotia-1, and Newfoundland-7). Most respondents (29) hold a Master’s degree in speech-language pathology (3 did not specify their level of education). Work settings included hospitals (12), schools (9), private practice (5), fluency clinics (2), and unspecified settings (4). The mean years of professional experience in treating people who stutter was 9.4 (range, 3 months to 23 years); mean number of clients assessed and treated was 47.4 (range, 1 to 200) and 43.9 (range, 1 to 200), respectively. Definitions of stuttering highlighted speech characteristics only (13) or combined with secondary behaviors (8) or emotional concornitants (5). Other definitions were more person-focused (2, e.g., fear or perception of losing control) or combined factors above (4). Causal explanations included physiological (21), genetic (17), environmental (13), psychosocial and language (6), and multifactorial (28) (i.e., some respondents reported more than one causal explanation). Of the 16 clinicians who reported working with preschoolers, assessment methods included parent interviews and case histories (9), calculating percent of syllables or words stuttered (7), identifying speech characteristics in varied speech contexts (6), assessing speech and language and analyzing parent- child interaction (4), and working within a play format (3); treatment methods included direct teaching of fluency skills (9), parent counseling and environmental modification (8), use of the Lidcombe program (6), other methods for teaching fluency enhancing strategies to parents (5), and indirect intervention (3). Of the 20 clinicians working with school-age children, assessment methods included parent interviews or case histories (9), frequency counts (8), attitude assessment (7), analysis of speech in varied contexts (6), child interviews (4), and speech and language assessment and rate calculation (3); treatment methods included teaching fluency skills (14), Lidcombe program (7), Comprehensive Stuttering Program-CSP and addressing attitudes (5), educating the child about stuttering (4), and parent counseling (3). Of the 14 clinicians who work with adults, assessment methods included case histories and attitude assessment (7), oral reading (9), conversational analysis (5), and assessment in varied contexts (3); intervention methods included fluency shaping (5), confronting feelings and attitudes (7), and the CSP (4). Factors influencing intervention included previous experience with specific me ;hods (10), academic training (9), input from colleagues (8), social/professional role of the client (2), and evidence-based practice (2). Issues that challenge the intervention process included geographic distance (7), time constraints and caseload size (3), and economic factors (2). Other challenges included unrealistic expectations and lack of support from parents (18), client motivation (6), and client or family denial or psychological problems (3). Despite the challenges, clinicians emphasized the importance of remaining flexible in designing treatment (13) and remaining positive (3). Beyond speech fluency, clinicians seek to increase the client’s self- esteem and self-acceptance (19), ability to realize life- and career goals (9), and to serve as a client advocate and public educator (6).

Chile (A. Bruna and N. Moses)
Seven clinicians completed the survey in Santiago; all have a university degree in speech- language pathology. Work settings included private practice (7), university (5), school (5), government clinic (1), hospital (1), and health agency (1). Professional experience with people who stutter ranged from 5 to 10 years (1), 10 to 15 years (2), 15 to 20 years (2), and greater than 20 I28 Theory, research and therapy in fluency disorders
years (2). Clinicians reported experience with preschool children (4) and with school-age children (4; one reported experience with both groups); the number of clients served over the last 5 years ranged from 5 to 100. The majority of the clients were female. Definitions of stuttering focused on behavioral symptoms (6); some referred to emotional/situational characteristics (4). Causal factors included biological (6, e.g., neurophysiologic, genetic, organic), emotional (1), discourse/ linguistic (1), and learning (1). Among the public in Chilean society, stuttering is generally thought to be of psychological and neurological origin. People who stutter, therefore, often are referred to neurologists who may prescribe medication (e.g., Haloperidol); others are referred to psychologists or phonoaudiologists (i.e., professionals trained as speech and language therapists). Two clinicians indicated treatment for children addresses emotional (i.e., by increasing the client’s confidence level), physical (by relaxation techniques), and physiological (by speech modification strategies) factors, through gradually increasing degrees of challenge. One clinician emphasized the positive impact of vitamins and nutrition on fluency; he works to lower anxiety level during communication by slow speech and hyperarticulation. The remaining clinicians (4) engage in family intervention, support to maintain realistic expectations for the treatment process, and counseling to address attitudinal issues. Factors influencing treatment included clinicians’ idiosyncratic views (e.g., stuttering is part of one’s personality) and theoretical perspectives (e.g., bioethic - patients’ independence from clinician; ecologic/ethonographic - use of strategies that are easy to use in a social environment; and global - considering the family, environment, patient, and finally the speech impairment). Other factors included a commitment to the patient-clinician relationship, a socio-cultural framework (therapy styles are influenced by a wider view of beliefs, interests, and needs), and socio-economic realities (therapy is mostly provided privately, is poorly reimbursed, and there is little public coverage). Obstacles included lack of family participation and/or commitment, limited access to current research, misinformation being promoted by the media, and fiscal realities. Yet, clinicians aspire to help patients realize their potential for personal growth (self-esteem, self-acceptance, ownership of communication experiences) and social integration (participation in society, resilience and assertiveness, better quality of life), in addition to improved effectiveness as a communicator.

France (A-M. Simon)
Twenty seven professionals completed the survey, 25 of whom are speech pathologists. All but one work in private practice; one works in a professional center. All were trained in language intervention; they gained their training in stuttering through continuing education. Note that in France, other professionals treat stuttering (e.g., neuropsychiatrists, psychotherapists, hypnotherapists, etc.). Professional experience of 10 clinicians ranged from 9 to 20 years; the remainder had more than 20 years experience. The number of patients served during the last 5 years ranged from 10 to 300; most clinicians saw between 30 and 100 patients. Age of the patients ranged from 2 to 65 years. Definitions characterized stuttering as a communication disorder (21), motor disorder with emotional or neurophysiologic involvement (14), symptom (2), disorder of inner time (1), and personality factor (1). Causal explanations included genetic (5), perpetuating factors (10), psychological (10), multiple (9), and unknown (2). Intervention with preschool children includes counseling parents (20), modeling (4), and environmental management (5). Less frequent methods are easy talking, relaxation, and psychotherapy. Intervention for school-age children focuses more on breathing (7), relaxation (9), fluency techniques (14), play intervention (10), and attitudes/social intervention (13). Intervention for adults uses mostly fluency techniques (14); less frequent are hypnosis, sophrology, kinesthesy, cognitive restructuring/desensitization, and transfer activities. Factors influencing intervention include cultural (10), social (4), educational (3); others are political, economic, geographic, and religious. Obstacles encountered include a gap between clients’ and clinicians’ expectations, resistance to change and lack of client commitment, shortage of time, treatment interruptions, and bilingual/cultural aspects. Beyond speech fluency, clinicians seek improve clients’ communication independence, personal freedoms, acceptance of self and others, and overall humanism (“If you are in peace with yourself, you’ll be in peace with the world around.”).

Germany (M. Abbink)
Of the 17 professionals who completed the survey, 10 are speech therapists (logopedics) working in private practice. The others are clinicians (speech therapists, speechorthopedagogs) with training in speech and language who work in private practice or the schools. Professional experience ranged from 1 to 31 years; most work with more children than adult patients. Stuttering was generally defined as a fluency disorder; one defined it as a breakdown between the body and soul. Causal explanations included genetic, neurophysiologic, psychic, organic, coordinative, and personality. The public in Germany commonly views stuttering as a psychological manifestation. Children are assessed through observation of parent-child interaction, play/conversational interaction, and parent and teacher interview; adults are assessed through analysis of videotaped conversations, questionnaires, tests, and occasional family interviews. Treatment with children primarily follows the work of Carl Dell; with adults other programs (e.g., Van Riper, Katz-Bernstein) are followed. Some clinicians emphasize desensitization, building self-esteem, and transfer more than others; fewest clinicians use hypnotherapy and treatment of their own design. Factors influencing treatment design included individual client needs, clinicians’ experience and training, and social concerns. Challenges included parent cooperation, shortage of time for interaction with parents, cultural and linguistic barriers, client motivation, clinicians’ feeling less than fully prepared to work with people who stutter, and public misinformation and lack of acceptance of stuttering. Despite the challenges, clinicians aspire for clients to achieve communication independence, acceptance of themselves, and greater self-esteem, in addition to providing the public with information about stuttering so as to change attitudes and misperceptions. Several clinicians expressed ultimate objectives in these ways: “Communication ability is a freedom of a human being.” “ If you can bring peace in your own mind, you can bring peace into the world.” “ I see stuttering therapy as one of many possibilities to decrease human suffering.”

Iceland (J. Einarsdottir)
Iceland is a country of approximately 280,000 inhabitants. About 46 speech and language pathologists are members of the Icelandic Speech and Language Association, 34 of whom currently work in the field. Of those, 13 work with people who stutter; all 13 completed the survey. They were educated in 5 different countries (Norway, Denmark, Sweden, Germany, and the USA); they have worked with people who stutter for 8-26 years. The evaluation experience with people who stutter ranged from 10 to 350 clients; treatment experience ranged from 20 to 220 clients. Work settings included the schools (7), private practice (4), and health service (2). Clinicians’ definitions of stuttering included behavioral descriptions, psychological factors, and voice spasm. Causal explanations were neurological-genetic-environmental (8), psychological (3), and unknown (2). The general public in Iceland assumes stuttering to be a learned behavior caused by environmental and psychological stress, and that preschool children will outgrow their disfluency. Assessment with preschool children includes parent interview and play interaction, speech sampling and analysis, and phonological and language assessment; intervention includes environmental management (indirect) and the Lidcombe program (direct). School children and adults receive fluency shaping and stuttering modification. Note that the state, school centers, or the state”˜ insurance company is responsible to cover most of the cost of assessment and intervention. Factors influencing intervention design included treatment setting, access to treatment due to clients living in remote areas, caseload size, treatment time, and age of the client. Providing fluency treatment for preschoolers is controversial. Obstacles included clinicians feeling less than fully prepared to work with people who stutter, disagreement among experts in fluency, infrequent referrals, and parents’ unrealistic expectations and feelings of helplessness. Those who indicated an objective beyond speech fluency (7) referred to increasing self-confidence and communication in modern society (“To accept the stuttering, to know oneself, helps the person to deal with life.”).

Japan (S. Miyamoto)
Twenty five clinicians completed the survey, including teachers of special classes for children with speech-language disorders (9), instructors in colleges or schools to train speech-language therapists (6), therapists who work for specialized public medical institutions (4), therapists in hospitals (3), psychologists (2), and a supervisor of school studies (1). Among them, 13 hold the speech-language-hearing license; 12 do not. Most of those not holding the license are the teachers of special classes. Note that licensing for SLHT in Japan began in 1999; while in transition, different professionals in allied medicine and education who meet specific guidelines are permitted to work with people who stutter. Also, therapy for people who stutter is provided mainly in hospitals, specialized facilities, or Tsukyu (resource room) classes for children with speech and language disorders in elementary schools. Professional preparation included training at the 3-year (vocational), 4-year, or 6-year level; several respondents had Master’s (3) or doctoral (2) degrees. Clients treated by the respondents included preschool children (8), school-age children (6), both (4), adolescents and adults (2), and all age brackets (5). Professional experience over the last 5 years ranged from less than 10 clients (13), 11 to 30 clients (8), to 31 to 71 clients (4). Clinicians’ definitions included behavioral characteristics of stuttering and avoidances (8), nervous talking related to anxiety and mental strain (9), repression of speech (1), an inability to adapt to human relations, and a broader communication breakdown. Causal factors included speech motor control caused by depression of the limbic system (6), multimodal theories (5), minimal brain damage (5), primarily organic factors mixed with environmental factors (2), individual differences ( 1), language disruption (1), and unknown and other (5). Assessment with younger clients typically involves assessment of speech symptoms and investigation of the parent-child relationship; communication attitudes are explored with older clients. Treatment with preschool children involves parent counseling (12) and play therapy (10); school-age treatment includes counseling children (10) and direct methods (10). Fewest clinicians work with adolescents and adults; those who do report using direct methods. Factors influencing intervention included the clinician’s educational experience and the client’s personality and multiplicity. Obstacles included conflicting views between parents and clinicians, misinformation about stuttering, lack of cooperation among professionals, and insufficient training to work with people who stutter. Beyond speech fluency, the overriding motivation of clinicians is improving clients’ quality of life for people who stutter (16); “The reason why I treat people who stutter is that they are able to live easily in this society.” Other objectives include active participation in society, improvement in general communication skills, and acceptance and understanding of stuttering and people who stutter.

The Netherlands (Y. Van Zaalen)

Eighteen speech therapists completed the survey, all of whom have completed the required ful1-time, 4-year university program in speech therapy. Stuttering therapy is an additional 2.5 years of post-graduate study, which was completed by 9 of the respondents. [Becoming a senior stuttering therapist requires reaching and maintaining a level of theoretical and practical mastery; “˜the number of respondents who hold this credential was not specified. There are 65 such specialists among the 2,200 speech therapists in Holland.] The respondents currently work in private practice (14), university hospitals (4), and schools (3). Years of professional experience ranged from less than 10 (3), 11 to 20 (8), and greater than 20 (7). Assessment experience over the last 5 years with clients who stutter ranged from less than 10 clients (5), 10 to 50 (4), to 51 to 350 (9); treatment experience ranged from less than 10 clients (5), 10 to 50 (6), to 51 to 250 (6). Definitions of stuttering included a breakdown in speech coordination, delineation of disfluent speech characteristics, involvement of internalized feelings, and a disruption of interpersonal communication. Causal factors included heredity, environmental, cognitive, respiratory, motor, emotional, neuromuscular, brainstem activity, and multifactorial. Intervention services are received by referral from a physician; medical insurance covers most of the cost for services, with restrictions. Assessment methods (i.e., not specified for age group) include video observation, play observation, interviewing the person who stutters and/or parents, speech analysis, emotional and non-verbal analysis; treatment methods include individual and group therapy, fluency shaping, stuttering modification, affective/cognitive treatment, breath management, speech-language management, stuttering diary, and available programs (e.g., Cooper, Webster, Van Riper, Hausdorfer). Factors that influence intervention included personality and dynamics of the family, cultural factors, professional training and academic preparation, professional literature, the therapist’s own beliefs, ideas from colleagues, and commitment to individual or group therapy. Obstacles included parents’ expectations and reactions, expecting a cure for stuttering, resistance to change, bilingual/cultural barriers, personal psychological problems, and reaction to relapse. Notwithstanding, clinicians aspire to enable clients to achieve self-management and personal acceptance, greater self-confidence, personal actualization, more relaxed and effective communication skills, and greater respect for one another (“Love is the most important”).

Poland (M. Abbink)
Of the 13 clinicians who completed the survey, 10 hold more than one job. They work in clinics (3), hospitals (1), kindergartens (4), schools (6), university (1), consultancies (2), and private practice (5). Professional preparation included a degree in pedagogics (8) or logopedics (speech- language, 5). In Poland, study of psychology, pedagogics, or Polish language and literature must precede study of speech-language therapy. Several clinicians specialized in different areas, such as stuttering therapy (balbutologopedics, 3), mental illness (oligofrenologopedics, 2), hearing impairment and deafness (surdologopedics, 1), aphasiology (1), and/or received additional training. Years of professional experience ranged from 4 to 32 years. The number of clients served over the last 5 years varied from only 2 (1), 4 to 60 (9 ), to 150 to 400 (3); most clients were male children. Stuttering was most often referred to as a loss of speech flow (8), citing factors including motor, respiratory, neuromuscular, phonatory, articulatory, fear of words (logophobia), and avoidance. Cause was attributed to genetic predisposition, delayed speech-language development, psychic or personal injury, and neurological factors. All clinicians do a complete assessment by interviews and observation; some use questionnaires and speech diaries; fewer use logopedical and irydological diagnostics (i.e., the latter refers to looking into a person’s eyes to detect diseases and disorders), psychotherapy, music and/or dance therapy, and botanics (herbal therapy). Relaxation is a frequently used intervention technique, as is slow speech and coordination of the respiratory, phonatory, and articulatory muscles. Both individual and group therapy is used; two clinicians work in speech camps. Factors that influence the design of treatment included clinicians’ previous professional experiences, the patient’s age and personality, and social and educational experiences of the participants. Significant obstacles included economic limitations (some treatment is supported by the Sick Fund), clients’ or parents’ motivation, shortage of treatment time, misinformation and lack of understanding/acceptance of stuttering, insufficient training or knowledge of the therapist, and lack of coordination among professionals. Yet, despite the obstacles and beyond speech fluency, most clinicians (8) seek to increase the self-esteem and self-acceptance of the person who stutters. In other words, “Above all - at once getting to know one’s self, one’s body, one’s behaviour, one’s goals, one’s emotions, one’s family, and one’s role in this family.”

Russia/Ukraine (I. Reichel)
Twenty professionals from Russia and the Ukraine (both of the former USSR) completed the survey. These included speech-language pathologists (15) and an education psychologist (1) who graduated from the Defectology Department of the State Pedagogical Institutes, physicians (3), and a physicist (1). Work settings included research institutes (7), hospitals (6), outpatient clinics (5), and private schools (2). Professional experience with people who stutter ranged from 1 to 10 years (5), 11 to 20 years (7), 21 to 30 years (3), and more than 30 years (5). The number of stuttering clients served ranged from less than 100 (9), 100 to 300 (6), and 300 to 600 (5). Most serve children and adolescents (7) or people of all ages (7); others Work With children between age 6 and 12 years (4); a few work with children younger than 6 years (2). Stuttering was primarily referred to as an abnormal rate-rhythm organization of speech as a result of the spasmodic condition of the respiratory, vocal, and articulatory areas of the speech apparatus (11); fewer defined stuttering as a 132 Theory, research and therapy in fluency disorders condition of genetic, emotional, or neurotic origin (7); fewest referred to a condition based on an organic and environmental imbalance (2). Causal assumptions overlapped with definitions. Most attributed stuttering to an impairment of the central nervous system, manifested by an abnormal cortical-subcortical relationship, affecting the speech muscles; fewer to a predisposition to neurotic or psychogenic symptoms; fewest to stressful social environments, psychological trauma, and internal conflict. Intervention approaches include diaphragmatic breathing (7), easy vocal onset (6), controlled rate and rhythm (5), and mixed approaches (2, medication, counseling, psychotherapy). Other approaches include role playing, teaching emotional control, manual therapy, and spinal relaxation, particularly to address the affective elements. Didactic principles included professional collaboration (9), counseling and training of parents (5), gradual increase in linguistic complexity (5), individualized treatment design (4), multimodal approaches (1, arts and crafts), and consistency and order (2) (several reported more than one principle). Factors influencing intervention included client age and cognitive/educational level, stuttering characteristics (severity, localization, situation), bilingual and cultural factors, educational and professional level of the client, and clients’ and clinicians’ previous clinical experiences. Obstacles encountered included lack of technology and equipment, self-help groups, client and family motivation and follow through, professional collaboration, understanding and acceptance of stuttering; other obstacles included economic (families who are unable to pay for service), alcoholism, guilt, blaming children for their stuttering, and lack of trust in professionals. Despite significant obstacles, clinicians work to improve the quality of life of people who stutter, to achieve “harmonization of the personality of the client who stutters,” and “to enable people who stutter to adapt and function in society.”

South Africa (M. Bortz)
Seventeen professionals completed the survey. All had completed the basic honours degree (typically a Bachelor’s degree, guided by ASHA requirements for the Master’s degree in the USA); two had a Master’s degree; one had a Ph.D. Years of professional experience ranged from little (newly qualified graduates) to over 50 years. Work settings included private practice (9), academic institutions (4), hospitals (5), community health centers (1), schools (2), and Speakeasy (1) (several work in more than one setting). Assessment experience over the last 5 years with people who stutter ranged from less than 10 (7), 10 to 50 (4), and 51 to 185 (6); treatment experience ranged from less than 10 clients (8), 10 to 50 (6), and 51 to 150 (3). Of those responding, most worked with clients of all ages; only 2 worked with adolescents and/or adults only. Definitions included delineation of disfluent speech-characteristics (6), secondary symptoms (6), emotional elements and reactions (5), and motor elements (2). Causal factors were multifactorial (10), genetic (10), neurogenic (9), environmental (7), stress/emotional (6), physiological or motor (4), and linguistic or multilingual (4). Assessment procedures utilize case histories (10), speech analysis (12), emotion/attitude analysis (7, some use scales and hierarchies), reading; assessment of children includes language and pragmatics, usually within play. Treatment procedures generally follow the work of international experts (Onslow, Luper & Mulder, Guitar, Rustin, Starkweather, Van Riper, Shine, Breitenveldt, Conture, Cooper, Gregory). With children, treatment is often conducted in the context of play, with hand puppets representing smooth speech and gentle prolongation; adult treatment is conducted individually and in groups and addresses affective, behavioral, and cognitive elements. [Note that traditional beliefs and attitudes of Black South Africans about stuttering are heavily influenced by Indigenous Healers, variously described as “psychologist, physician as priest, and tribal historian.” For example, presumed causes of stuttering include accumulation of coagulated milk in the throat, leaving the baby out in the first spring rain, failure to inform ancestors of imminent childbirth, and witchcraft; management includes medication, prayer and ritual, parent counseling, treatment for a mental disorder, and topical medication applied to cuts on throat area. Many Black South Africans seek the services of Indigenous Healers in preference to western medicine.] Factors impacting treatment among the professionals sampled include economic, geographic, political, social, linguistic (bilingual, multilingual, multicultural); others included the needs of the individual client, anxiety level, and family structure. Obstacles encountered included follow through of clients and families, stress and marital problems in the home, level of knowledge within the public about stuttering, materials that are culturally inappropriate, and general resistance to change. Beyond speech fluency, most clinicians seek to improve the self-esteem and general communication ability of people who stutter; “to change misconceptions, promote tolerance, and provide a verbal gift that everyone is entitled to.”

United Kingdom (F. Cook)
Of the 27 respondents to the survey, 74% are employed by the National Health Service, all (100%) are State registered following a 4-year Honours Degree Course or 2-year Master’s Degree, 93% specialize in stuttering (22% also engage in research), 63% have practiced between 10-25 years, 63% treat all age groups (major focus is on children), and 37% either treat children or adults only. Definitions included both cognitive and behavioural characteristics. Causal explanations generally assumed a genetic predisposition with an underlying motor processing problem; risk" of persistence would include developing psychosocial factors. Assessment methods include fluency analysis (100%), case history and interview (92%), language assessment (30-60% for children), cognitive/behavioural issues (70-80% for older clients), and identification of risk factors (80% for children). Intervention methods reported by 96% include parents (with preteens), indirect (focused on the communicative environment), and direct (fluency strategies). Older children through adults receive cognitive behavioral methods, social communication skills, problem solving, and avoidance reduction strategies. Factors that influence the intervention methods included the guidelines for best practice from the Royal College of Speech and Language Therapists, National Health Service clinical governance procedures, and workforce and funding barriers. Key influences on an individual basis included training, continuing professional development, supervision, reflective practice, and the professional literature. Other challenges to the therapy process included clients’ and significant others’ beliefs and expectations about therapy, limited resources, difficulties of delivering the right amount of therapy where and when the client needs it, and being flexible in providing treatment across cultures and other barriers. Beyond speech fluency, clinicians aspire to promote client empowerment, self-advocacy, knowledge, choice and acceptance (of stammering) for the individual and by the wider community.

United States of America (L. Molt)
Twenty five clinicians completed the survey. All met the requirements for ASHA’s (the American Speech-Language-Hearing Association’s) Certificate of Clinical Competence (i.e., a Master’s degree in the discipline, prescribed clinical experience, and a passing score on a national exam); 8 are Board Recognized Fluency Specialists (an additional credential requiring post-graduate continuing education and experience in treating people with fluency disorders). Work settings included public schools (11), university-based speech clinics (6), private practice (5), hospital-based clinics (2), and public health agencies (1). Professional experience in years ranged from 1 to 5 (6), 6 to 10(5), 11 to 15 (7), and more than 15 (7). Experience over the last 5 years with people who stutter ranged from 12 to 200 (mean, 26.4 clients). Demographics of the individuals receiving treatment varied with the practice site (school-based clinicians treat clients ages 3-21 years, with the majority aged 5-10 years; private practice clinicians see clients from 1-90 years of age). Most definitions of stuttering characterized a breakdown in speech flow, rhythm, or speech motor behavior; listed core or secondary behaviors; and addressed emotional or internal manifestations. Causal interpretations included such factors as genetic, environmental, neurological, motor, learning, and mixed: published surveys indicate that the public in the USA views stuttering as arising from insecurity, psychological problems, and parental mishandling. For preschool children, assessment and intervention includes collection of case history, assessment for concomitant disorders, speech analysis from play-based interaction, parent interaction, environmental management; some prefer direct approaches (e. g., Lidcombe program), others vary the demand according to the capacity of the child. With school- age children, there is often less parent involvement, favoring more direction to change speech production patterns while adopting a slower rate of speaking; others teach effective communication 134 Theory, research and therapy in fluency disorders patterns and relaxation, and eliminate secondary behaviors. Attitudinal and cognitive intervention is used more with older, than with younger, children. For adolescents and adults, cognitive coping strategies are emphasized more in addition to speech management; some utilize neuropharmacolgical interventions, self-help organizations, and assistive devices. Factors influencing intervention included characteristics of the patient and culture, available assessment tools and intervention approaches, models of service delivery, and financial issues (insurance coverage). Related obstacles included unrealistic expectations of clients and families (i.e., perfect fluency), shortage of treatment time, and limited availability of allied professionals for collaboration. Yet, clinicians’ overriding motivation continues to focus on improving communication of the whole person, building self- confidence, maximizing access to resources in society, and building interpersonal communication skills.

  1. Similarities and Differences
At first glance, looking at the contributions of diverse clinicians, one is hit not with the professional differences, but with the many striking similarities around the globe. All of the participants shared that our profession is delivering services to people of all ages in a variety of settings (e.g., hospitals, private practices, public and private schools, government public health agencies, university speech and hearing centers). Our methods vary as a reflection of the nuances in our definitions, causal assumptions, and underlying constructs and rationale. Stuttering was defined as a disorder, disruption, and interruption in the forward flow of speech; others focused on the behavioral symptoms, cognitive/emotional components, perceived loss of control, disorder of timing, personality factors, and voice spasms. Causal explanations included genetic/heredity, environmental, neurological, motor/physical, physiological, psychological, psychosocial, linguistic, learning, emotional, variable, and unknown. Preschool intervention typically involves family-based interaction, communication modification (e.g., slow speech, syllable stretch), and direct (e.g., Lidcombe program) and/or indirect (parent counseling; play intervention) teaching of fluency skills. School-age intervention involves attitude modification, tension reduction, interaction with teachers and family members, slow speech modeling with soft onsets and pauses, Lidcombe program, parent involvement, teaching fluency skills, Comprehensive Stuttering Program, and focus on breathing/relaxation. Adolescent and adult intervention involves cognitive reorganization, gentle speech, self-help, avoidance prevention, unrestrained and pseudo-stuttering, attitude modification, fluency shaping/stuttering modification, use of assistive devices, and occasional hypnosis. Factors that influence the design of treatment are fairly consistent, including empirical evidence, clinicians’ academic training and experience with specific clinical methods, input from professional colleagues, individual client’s strengths and needs, social/professional role of the client, and religious, social, political, educational, economic, cultural, and language/linguistic factors. Other challenging issues included geographic distance from treatment, misinformation (i.e., in the media, schools, public, medical profession), shortage of speech-language pathologists and self-help groups, absence of specialized training in stuttering intervention, shortage of time and resources to meet the demands of heavy caseloads, clients’ unrealistic expectation of a “quick fix,” conflicting views between clinicians and parents and among professionals, and resistance to change and lack of motivation in treatment (i.e., clients, families). Our context for service delivery and preferences for communication targets vary within each diverse clinical and cultural context. We love what we do, despite the occasional frustrations. We aspire to enable people who stutter to achieve their own freedom of speech. Furthermore, our overriding motivation is to enable others to realize their unique potential, thereby gaining access to, enjoying, and creating opportunities within a communicative/social context.

Differences provide intrigue but wane in light of the similarities. Some differences were observed in the required professional preparation, definitions/causes,intervention practices, and payment systems. In most countries sampled, professional preparation for clinicians to assess and treat people who stutter requires either a Bachelor’s or Master’s degree. However, some countries require less training and not all require training in the area of stuttering. In Japan, for example, clinicians can practice with three years of vocational training, a Bachelor’s degree, or a Master’s degree. Each country has identified a core of professionals who have a special interest in treating people who stutter. In most cases, that specialization is informal; in two, specialization has been institutionalized (i.e., Holland, USA). It is interesting that in some of the countries sampled, professionals in addition to speech-language pathologists provide services to people who stutter. In Chile, other providers include neurologists (i.e., stuttering is assumed to be of neurological origin) who prescribe Haloperidol and psychologists (stuttering is assumed to be of psychological origin).

In France, other providers include neuropsychiatrists, psychotherapists, and hypnotherapists. In Japan, some people who stutter are treated by allied medical and educational personnel; in Russia and the Ukraine, some are treated by educational psychologists, physicians, and physicists. Some of the most striking distinctions in providers and services are observed in South Africa (i.e., refer back to South Africa, specifically the Indigenous Healers, referred to as “psychologist, physician as priest, and tribal historian”).

Some differences were observed in definitions and perceived causes of stuttering. In Japan, stuttering was defined as nervous talking related to anxiety or mental strain, repression of speech, inability to adapt to human relations; causality was attributed to depression of the limbic system, minimal brain damage, and breakdown between the body and soul. In Japan and in Russia and the Ukraine, stuttering was thought to be the result of impairment to the central nervous system. In addition to traditional assessment in Poland, some providers use logopedical and irydological diagnostics (i.e., looking into a person’s eyes to detect disease and disorder); others use psychotherapy, music and dance therapy, and botanics (herbal therapy) for intervention. When serving preschool children, controversies included the degree of intervention directness, involvement of family members, and use of psychotherapy. Providing treatment for preschool children in Iceland is controversial; the public assumes that stuttering is a learned behavior of psychological and environmental origin and that preschool children will outgrow their disfluency. Providing treatment for adults in Japan is controversial; stuttering is assumed to be of psychological origin, requiring counseling services to enable the client to accept his communication disorder. Financial resources allocated to health care and service delivery vary as well; the consensus indicates that fiscal realities continue to be a significant factor in accessing and providing services.

  1. Closing

This paper has only begun a process of inquiry. The participants and the sample of clinicians each surveyed are not maximally representative. This was underscored by a question raised by M. Bortz (“What would the results of the survey have been if we included other service providers, not speech-language therapists, who work with people who stutter, e.g., Indigenous Healers?”). A wider and more representative sample would be telling, particularly as we look at the efficacy of traditional and alternative forms of treatment for stuttering. Follow-up interviews with the service providers, clients, and families would enable more precise comparison within and across countries (i.e., in some cases, the survey questions resulted in disparate responses). Clearly, the topic of professional

preparation from a multinational perspective should be investigated, as should that of specialization and specialty recognition in the area of fluency disorders within diverse countries. The less visible aspects of stuttering (i.e., the emotional and cognitive) continue to invite a more disciplined form of inquiry. The field of fluency disorders is ripe with questions and fertile territory for research.

One of the major purposes of the this session at the IFA Congress in Montreal was to bring colleagues together from around the globe to share, to distill, and to learn and grow from the experiences of all who treat and care for people who stutter. While this international research project is ongoing, preliminary results reveal a commonality of purpose among multinational service providers, the importance of working together and communicating across international borders, and a window into the world as a global classroom.

Thanks to all of the presenters, clinicians, and participants who have contributed to this work and who have shared their theoretical and clinical ideas and their professional passion. As a profession, we are one. We are united by our universal commonalities, our chalenges, and our beliefs. Efforts such as this bring people together from diverse lands, enabling us to explore our common goal of improving the lives of people who stutter. We set an example :0 other groups around the world for how seemingly insoluble problems can be addressed by constructive and positive means, indeed by communication. That is our business - no, that is our caling - using our freedom of speech to construct a greater understanding, a more harmonious existence, and a more peaceful world. That is our wish.

Pickering, M. (1994). The unexpected, the amazing, and the elusive: Applying international perspectives to clinical education. In M. Bruce (Ed. ), Toward the 2 I st century: Proceedings of the I 994 International and Interdisciplinary Conference on Clinical Supervision (pp. 68-81). Burlington, VT: University of VT.

Pickering, M. (1995, Spring). Being a professional in a borderless world. Australian Communication Quarterly, 16-17, 20-21.

Pickering, M., & McAllister, L. (1997). Clinical education and the future: An emerging mosaic of change, challenge, and creativity. In L. McAllister, M. Lincoln, S. McLeod, & D. Maloney (Eds.), Facilitating learning in clinical settings (pp. 252-295). London, England: Stanley Thornes.

Pickering, M., & McAllister, L. (1998). Cross-cultural interaction: An essential component in speech-language pathology clinical education and professional development. In P. Dejonckere & H. F. M. Peters (Eds.), Communication and its disorders: A science in progress: Proceedings of the 24th Congress of International Association of Logopedics and Phoniatrics (Vol. II, pp. 946-949). Amsterdam, The Netherlands: Nijmegen University Press.

Pickering, M., & McAllister, L. (2000). A conceptual framework for linking and guiding domestic cross-cultural and international practice in speech-language pathology. Advances in Speech- Language Pathology, 2 (2), 93-106.

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

Shapiro, D. A., Molt, L. F., Lundberg, A., Reichel, I., Ohashi, Y., Simon, A., Wahlhaus, M. M. (2000). Multinational understanding through stuttering intervention: Diverse influences and global lessons. In H-G Bosshardt, J. S. Yaruss, & H. F. M. Peters (Eds.), Fluency disorders: Theory, research, treatment, and self-help/Proceedings of the Third World Congress on Fluency Disorders in Nyborg, Denmark (pp. 505-512). Nijmegen, The Netherlands: Nijmegen University Press/International Fluency Association.

Shapiro, D. A., Molt, L. F., Lundberg, A., Reichel, I., Ohashi, Y., Simon, A., & Wahlhaus, M. (2001, Juin). Le traitement du begaiement: Son approche selon differents pays, influences diverse et lecons generales. Reeducation Orthophonique, 206, 113-126.

Shapiro, D. A., & Moses, N. (1989) Creative problem solving in public school supervision. Language, Speech, and Hearing Services in Schools, 20, 320-332.


A Multinational Investigation of Stuttering Intervention: Assumptions, Practices, and Lessons

This international research project invites speech-language pathologists to complete a lO-item survey for the purpose of determining the intervention methods used in different countries to manage people who stutter, the factors influencing those intervention methods, and the ultimate purposes served and lessons learned. The benefit of this project will be in creating an opportunity for clinicians to learn with and from each other across national borders. Responses to the survey questions will be used to determine group trends only. No names or other identifying information will be attached to any of the responses to the survey; all information will remain confidential. Completion of the survey will take approximately 10 minutes. As a speech-language pathologist who desires to learn from others, I encourage you to participate. However, you should feel free to decline this invitation or to withdraw your participation at any time.

Thank you in advance for your consideration. The procedures being used in this investigation have been approved by the Institutional Review Board at Western Carolina University. Your signature indicates that you are providing informed and voluntary consent to participate in this project.


David A. Shapiro, Ph.D., CCC-SLP Institutional Review Board Professor c/o Research and Graduate Studies Western Carolina University Western Carolina University Communication Disorders Program HFR Administration Building'440 Department of Human Services, Killian 204 Cullowhee, NC 28723

Cullowhee, NC 28723 USA

Stuttering: Clinicians’ Assumptions And Intervention Practices

This questionnaire seeks information about your professional experiences with people who stutter. Please respond to each question as accurately and completely as possible. You are welcome to continue your responses on the back of the page or on separate pages. All responses will remain confidential. Thank you for your participation.

  1. Please describe your professional role and your work setting (e. g., public school, private school, hospital, professional clinic, etc.). If you are other than a speech therapist, please specify and describe that role.
  2. Describe your professional preparation and indicate how many years you have served in your professional role.
  3. Over the last five years, how many people who stutter have you assessed? How many have you treated? What were their approximate ages and genders?
  4. Different people mean different things by the word “stuttering.” How do you define stuttering?
  5. In your opinion, what causes stuttering?
  6. Describe your intervention with people who stutter. In other words, how do you conduct assessment and treatment for a preschool child, a school-age child, an adolescent, an adult, and an elderly adult? '
  7. What factors influence what you do as a clinician in assessing and treating people who stutter (i.e., why do you use the methods you use)? For example, how might your methods be influenced by cultural, political, social, educational, economic, geographic, or other factors? What are your guiding principles for intervention?
  8. Often our clinical efforts are directed toward influencing the affective, behavioral, and cognitive factors related to speech fluency. From a broader perspective, what do you strive to achieve (i.e., other than speech fluency) by virtue of what you do professionally? For example, one might think that our work demonstrates that improved communication is possible, thereby contributing toward global understanding and world peace.
  9. What obstacles have you encountered in assessing and treating clients who stutter and their families? What lessons have you learned?
  10. Please add any other comments, reactions, or suggestions about intervention with people who stutter and their families not covered above.
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