2003 IFA Congress: Montreal, Canada

Synergistic Stuttering Therapy: The Counseling Connection

Donna K. Cooperman, and Charleen M. Bloom
The College of Saint Rose, Albany, New York, USA 12203


The synergistic approach to stuttering treatment combines the techniques of fluency shaping and stuttering modification. In this approach, the elements of normal speech production: articulation, phonation and respiration are described and the client is taught to modify these targets in his or her speech to approximate the patterns of normal speakers. At the same time the client learns to explore attitudes and feelings related to stuttering and to understand and modify the environments in which he or she speaks most frequently. The components of the synergistic approach are Speech-Language, Attitudinal, and Environmental. Each of these components operates in an interactive, interrelated mode. I: is because of this perspective tha: the treatment program is described as holistic. As such, the counseling skills of the clinician are fundamental to the treatment program.

  1. The counseling connection
Crowe (1997) reminds us that counseling occurs in almost every therapy encounter, whether it is intentional or spontaneous. He asserts: “Counseling is not only appropriate but necessary in order for clients to receive maximally accountable services that include both adjustment counseling and informative counseling.” (p.21). We would argue that intentional counseling should be the foundation and framework for our clinical work with fluency clients. This perspective is supported by the American Speech-Language and Hearing Association in its Preferred Practice Patterns (1993) and Scope of Practice in Speech-Language Pathology and Audiology (1993). Despite these mandates by ASHA, many, including our own colleagues, have questioned the role of the speech-language pathologist as counselor. Schuerle (1992) has examined this issue and clearly supports our participaion in the counseling process, noting Carl Roger’s contention that counseling is no: in the singular province of psychiatrists or psychotherapists (p.17). Synergistic Stuttering Treatment, as practiced by the presenters of this paper, suggest identifying our role as one of clinician/counselor and relies heavily on the principles and skills derived from the counseling literature. This allows us to maintain our primary identity as speech-language pathologists and integrate the techniques of counseling that allow us to treat our clients holistically.

Brammer (1977) identified two views of counseling. The first sees counseling as a scientific/behavioral enterprise. The second sees counseling as a natural function that occurs in most human relationships. As speech-language pathologists we are called upon to demonstrate the balance that underlies these seemingly opposing views. We believe that counseling is both an art and a science. Although the skills and talents of the clinician impact the therapeutic relationship, a firm theoretical foundation is essential for effective understanding and integration of the counseling process.

Jones (1990) defines counseling as: “. . .the establishment of an effective interpersonal relationship within which client change and growth are fostered. The process is a collaborative effort in which an attempt is made to create conditions that allow change to occur. Its usual purpose is to help those seeking assistance to become more autonomous, more self -directed, and more responsible by fostering learning and providing the tools that individuals may need to make change”. The Synergistic Stuttering Treatment framework supports this definition of counseling and expands it to include the personal growth and development of the clinician/counselor. This View of the counseling process is depicted in Bloom and Cooperman’s (1999) Counseling Triangle.

The Counseling Triangle consists of three components: Theories/Issues, Skills and Personal Growth. These aspects of the process work together and assist the clinician/counselor in implementing counseling into fluency therapy. The theories are drawn from Adlerian, Rogerian, Existential, Cognitive, Gestalt and Family therapies. The skills, adapted from lvy (1994), include: attending behavior, observation, encouraging, paraphrasing, summarizing, confronting, and reflection of feeling and meaning. The personal growth and development component asks that the clinician/ counselor grow in awareness of his/her own person. Although we often recognize the importance of the therapeutic relationship in our profession and the qualities necessary for effective clinicians, we frequently neglect to highlight the elements of personal growth necessary for a successful clinical relationship. These elements include knowledge of self, understanding self-esteem issues, understanding assertiveness issues, understanding inner control, commitment to personal growth, and commitment to living consciously. Although we have identified these separately for the purposes of this paper, we understand that these components are synergistically related. Simmons- Mackie and Damico (2003) discuss the wealth of qualitative literature describing the synergistic nature of communication as a multilayered system. This synergistic framework applies, as well, to the interrelated components of the counseling triangle and the fluency treatment program.

  1. Overview of synergistic philosophy

Our synergistic philosophy grew from an integration of the research of such varied investigators as: Smoluchas (1988), Wall and Myers (1984), Guitar and Peters (1980, 1991), Gregory (1979, 1986), Starkweather (1987), and St. Louis and Myers (1997). We support the View of stuttering as a complex, multidimensional disorder that is best analyzed and treated synergistically. We isolate the individual, social, cognitive and biological factors for each person and are aware of the effect of the interaction of these factors. Like Myers and St. Louis (1992) we support a systems approach that views the speech and language functions of communication as interrelated, noting the interaction of the physiological, psychological, linguistic and social components. (Figure 1).

SST f1

Figure 1. A Synergistic Approach to Fluency Therapy by C. Bloom and D. Cooperman (1999)

  1. Tools to implement counseling concepts
The two components of the Synergistic Treatment Program that apply to the counseling domain are the attitudinal concepts (which we call the empowerment attitudes), and the environmental concepts. The empowerment attitudes include self-esteem, locus of control and assertiveness. The environmental concepts include family systems, communication skills, and cultural influences. In order to provide effective stuttering therapy, clinicians need a variety of tools from each of these areas. The remainder of this paper will focus on these attitudinal concepts.

  1. Attitudinal concepts
Self-Esteem is defined by the California Task Force (Steinem, 1993) as appreciating one’s own worth and importance and having the character to be accountable for oneself and to act responsibly toward others. Brandon (1987) describes two components of self - esteem: a feeling of personal competence and a feeling of personal worth. He believes that self-esteem is the sum of self -confidence and self-respect; what one thinks and feels about oneself. We like to think of self -esteem as the reputation you have with yourself. We begin with self because self is the center from which all growth and change occur. Satir, Banmen,- Gerber & Gomori (1992) describe a self- mandala which we have adapted to meet the needs of people who stutter We design opportunities to address the physical, cognitive, linguistic, learning, emotional, attitudinal, family, communication and cultural dimensions of each individual’s personal needs and experiences.

We know that in order to grow in self-esteem, each individual must feel respected. It is important that we as clinicians connect with our clients at the level of the self and help them to recognize their own significance. Combs (1982), and Coopersrnith (1967) provide descriptions of the self-actualized person, with positive self-esteem. These descriptions provide guidance for us to assist our clients in setting goals for themselves in this attitudinal domain. Our clients have experienced growth in self -esteem in a variety of ways, including: experiencing mastery and competence, identifying their strengths and weaknesses, recognizing and accepting their successes and failures, identifying with other people who stutter, living and being responsible to the present, praising, affirming and accepting self and internalizing a positive self-image, being willing to take appropriate risks in the face of fear, acting independently while accepting responsibility for their choices and actions, and identifying, accepting and talking about their emotions and feelings.

As we provide these opportunities, our clients are engaged in a process of self-discovery rather than a fixed or rigid idea of self. Some of the experiencesiand activities that our clients have found helpful in this regard include leading our support group meetings , participating in interviews for radio, television, and newspapers, speaking to parent groups and fluency classes, giving after dinner speeches at an open microphone and profiting from the personal interactions and support found in group treatment. It is through these programs that they strive to reach the goals we have described. We recognize that positive self-esteem is not a prize that can be given to our clients. Rather it is the reward of their personal journey, one that they give themselves. In order to guide clients toward this self-discovery, the clinician/counselor must first have identified his/her own potential strengths and limitations. It is only with a high level of self-understanding that the clinician/counselor will be able to recognize client successes and provide the necessary support to help foster the development of an individual client’s self-esteem.

Locus of Control is defined by Rotter ( 1966) as an individual’s expectation that life’s outcomes are either under one’s personal control (internal) or a product of luck, fate, chance, or other people with power over us (external). Research (Lefcourt, 1984; Rotter, 1966) has demonstrated that individuals with an internal locus of control are more assertive, effective and competent than those with an externally balanced locus of control. Manning (2001) reports that treatment programs whose major focus is the client taking responsibility for speech management will show a greater intemality of control. He also points out that this will occur regardless of the level of fluency demonstrated by 142 Theory, research and therapy in fluency disorders the client. B1oom’s (1990) preliminary study confirmed that continuation in a maintenance program for five years is related to an increase in internal control and a decrease in frequency of stuttering.

Application of locus of control to fluency therapy may be achieved through awareness techniques, cognitive therapy techniques, mindfulness meditation techniques and the use of transition videotaping.

One awareness technique that has served as a powerful tool for many of our clients is adapted from A1lenbaugh’s Stuck State Cycle (1994), a visual representation of the process by which a person either makes a choice to change or automatically and unconsciously chooses to repeat past, unsuccessful ways of coping with unwanted behavior. We use this as a device to encourage our clients to change their automatic and unconscious speech responses to those that are conscious and accountable. The Stuck State Cycle assists them in heightening their awareness of their choices. They may choose to stutter or not. They may choose to avoid situations or to take risks. They may choose to use speech targets or to stutter easily. Each conscious choice brings a direct result. The pause point of the stuck state cycle is the essential moment of choice. It is at this time that the client commits to a conscious, accountable action. Allenbaugh’s visual representation of the cycle is a highly effective motivational tool. .

One cognitive therapy technique that our clients have used successfully is the Triple Column Technique (Bloom & Cooperman, 1999), adapted from Ellis’ (1977) Rational Emotive Behavior Therapy and Burn’s (1990) The Feeling Good Handbook. According to Ellis, irrational thoughts should be explored through the process of therapy which he terms the “ABC’s of RET”. A is the activating event. B is the belief system we use to interpret the event. C is the consequence of the event (the irrational thoughts and feelings that arise from a negative belief system). D is the act of disputing irrational beliefs and E is the engagement of rational beliefs to replace the irrational beliefs. Our Triple Column Worksheet provides an opportunity for clients to identify the upsetting event that led to their negative thoughts, determine the distortions in their thinking (based upon Burns’ description of cognitive distortions), and replace negative thoughts with positive thoughts. We believe that engaging in this process is another way of demonstrating to our clients that they have control over both the physical and attitudinal dimensions of stuttering.

Based on the work of Ylvisaker and Feeney (1998), we have used transition videotaping as an empowerment tool. Clients periodically prepare a self-advocacy videotape in which they explain their treatment goals and the nature of their communication disorder. They then describe for the viewer some of their communication strengths and the intervention procedures that have been successful for them. When using this technique, clients seem to gain a greater sense of control and take increasing responsibility for their progress. They demonstrate insight into their strengths and needs and become more strategic in relation to their stuttering. These videotapes may be used for parent or family education, heightening teacher awareness, or promoting the client’s personal growth and responsibility.

Assertiveness has been defined by Butler (1992) as the ability to say what you feel and what you think without fear or embarrassment, while respecting other people’s feelings and opinions. Butler identifies four aspects of assertion that appear to be problematic for people who stutter: expressing positive feelings, expressing negative feelings, setting limits, and engaging in self-initiation. The ability to express positive feelings is a strength that adds to a person’s freedom, enjoyment and success in life. The ability to express negative feelings provokes fear in many people who stutter. They often have strong feelings related to their stuttering, and these need to be expressed in order for positive feelings to surface. Setting limits involves saying “no” when other people make demands 01”˜ requests that conflict with one’s own needs. When people set limits, they teach other people how to treat them. People who can set limits can demand the respect they are due. When working with people who stutter, setting limits becomes a primary focus, since many have endured mockery and insults since childhood. As people grow in self-esteem and internal locus of control, they are better able to respect their own personal needs and set the necessary limits for positive interaction. The final aspect, self-initiation, is a mechanism for saying “yes”. Our clients learn to take risks and initiate actions that they may have avoided in the past, out of their fear of stuttering.

Jakubowski-Spector (1972) identifies three types of behaviors related to assertiveness: assertive, non-assertive, and aggressive. Assertive individuals are honest, direct, and appropriate in their relationships with others, asserting themselves without violating the rights of others. Non-assertive individuals allow their rights to be violated by others, resulting in feelings of pain, anxiety, and anger. Aggressive individuals assert themselves at the expense of others. Their behavior suggests a lack of respect for another’s ideas or behaviors. In our experience, as individuals make initial strides in fluency they tend to move from non-assertive to aggressive behaviors and need to be guided in the principles of healthy assertiveness. It is easy to understand how an individual who has avoided interactions for fear of stuttering may have difficulty in learning the conversational conventions for appropriate pragmatic behaviors that many of us take for granted.

We use a variety of techniques to foster increased assertive behavior. We have adopted Butler’s (1992) concept of the Influence Analysis, in which the client is able to uncover family dynamics, as well as the dynamics of other influencers in the client’s life. For this activity, clients are asked to identify those individuals who have a strong influence in their lives. They then determine whether the influence is positive or negative and describe how they respond to those individuals. Finally, they are asked to describe their patterns of behavior with those individuals. This is a valuable tool for assisting our clients to become more assertive communication partners.

  1. Attitudinal measures and outcome data
A review of a random sample of the data we have collected on ten adult clients every 4 months over the course of one academic year demonstrates the treatment outcome of this aspect of the treatment program. The ten subjects were randomly selected from adult clients participating in the College of Saint Rose Council of Fluency.. The subjects ranged in age from 22 to 64. There were 3 women and 4 men. Treatment period ranged from 1 to 5+ years (4 clients had participated for 1 year, 3 clients had participated for 3 years, and 3 clients had participated for 5+ years). All treatment measures were obtained during ongoing therapy, as all 10 Clients continue in the program at this time. Attitudinal measures suggest an increase in positive attitudes toward communication as measured by the Communication Attitudes Scale-S-24 (Andrews and Cutler, 1974). Scores ranged from a pretest mean of 18 for the 10 subjects, to a post-test mean score of 12 . All ten subjects demonstrated a movement in attitudes toward more positive responses. Internalization of locus of control was measured with the Locus of Control of Behaviour Scale-LCB (Craig, Franklin & Andrews, 1984). Mean LCB scores for the 10 subjects ranged from a pretreatment high of 39 to 18 at the time these ongoing measures were obtained, demonstrating movement from externality to internality in 6 of the 10 subjects. For the six subjects that had been in therapy for 3-5+ years, LCB scores improved from a mean high of 46 at the start of treatment to a mean low of 14 at the time these measures were obtained. The remaining 4 subjects were relatively new to the program (i.e., they had participated for approximately 1 year) and had not had sufficient time to internalize locus of control. The scores of these 4 clients ranged from a mean high at the start of treatment of 42 to a mean low of 29 at the time of this 1 year measurement, indicating positive movement but continuing externality. Bloom’s preliminary study demonstrated that locus of control changes become more internalized after an optimum 5 year period when combined with a maintenance program (Bloom, 1990).

Self-esteem as measured by the Self-Esteem Scale (Rosenberg, 1979) showed a definite trend toward more positive self-esteem in 9 of the 10 subjects. It should be noted, however that 5 of these subjects entered therapy with relatively high self-esteem. Rosenberg’s scale is a qualitative measure, as the client’s responses to this 10 item Guttman scale are viewed in various combinations to determine positive or negative self-esteem. Results are expressed in terms of 7 scales contrived from these 10 items. The 5 clients who entered the program with relatively high self-esteem, scored positively on 5 of the 7 scales when they entered treatment, and 7 of the 7 scales at the time these measures were obtained. . The 5 clients who entered the program with relatively low self-esteem responded to the protocol by indicating Agree or Strongly Agree to such statements as they were unsatisfied with themselves, wished they could have more respect for themselves, and/or felt as though they were failures. The 4 clients whose self-esteem improved scored negatively on 4 of the 7 scales when they entered the program and positively on 5 of the 7 scales at this 1 year measure. The 1 client whose self-esteem did not improve scored negatively on 7 of the 7 scales at both the initiation of treatment and at the 1 year measure.

Assertiveness as measured by the Assertiveness Scale (Butler, 1992) indicated that the majority of subjects had the greatest difficulty in expressing negative feelings, setting limits and initiating interactions with strangers and people in authority. This scale identifies 13 categories of conversational partners and 4 communicative contexts, i.e., expressing positive feelings, expressing negative feelings, setting limits and initiating interactions. Respondents are asked to rate their level of difficulty with each category of person in each communicative context on a scale of 1 (easiest) to 4 (most difficult). Newer clients (i.e., 4 of the subjects) continue to have difficulty with self-assertion with the majority of communication partners, while clients who have been in treatment for 3 years or more (i.e. 6 of the clients) improved in all 4 contexts with a majority of communication partners. Although this scale does not offer normative data, movement toward assertiveness (i.e., lower numbers assigned) with these subjects was apparent in all four areas.

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