2003 IFA Congress: Montreal, Canada

Change: The Key To Success In Stuttering Therapy

Barbara Dahm
Communication Therapy Institute, I Hadar Street, Matan 45858 Israel


Successful stuttering therapy requires well-defined goals that will lead to the generation of fluent speech. The necessity of self-change is mandatory to achieve these goals. The combination of the speech processing model and a six-stage program of change shows how people who stutter can develop effective goals and take specific and appropriate steps to bring about the necessary change. A follow-up study explores how realistic it is to for people who stutter to make 1ong-term change and whether the effort to make self- change is worthwhile.

  1. Introduction
The outcome of stuttering therapy has not been encouraging. Even when the standard of success is downgraded from recovery to progress, Manning (1996) reports that “one-third of clients will make good progress; one-third moderate progress; one-third, often because they prematurely drop out of treatment, little or no progress” (p. 203). Nevertheless, there are people who have recovered from stuttering. Some individuals recovered after having undergone therapy (Boberg & Kully, 1994; Dahm & Kaplan, 2000; Ingham et al., 2001), while others did so without having had formal treatment (Finn, 1997; Harrison, 1997).

The contrast of persistent stuttering vs. incidents of recovery leads us to explore the possible differences between people who recover from stuttering and those who do not. One possibility is that the type or etiology of stuttering may affect recovery. Cooper and Cooper (1995) propose that there is a population of chronic stutterers who are not capable of recovery.

Another possible factor affecting the continuance of stuttering is the way individuals approach recovery. Some people who stutter enter treatment with the hope that therapy will be the “magic cure” or at least teach them a trick or technique to use when they are going to stutter. These individuals relate to fluency as an object to be acquired; their entire focus of attention is solely on the speech that is produced. They do not consider that both fluent and disfluent speech is the result of a process of speech production. Therefore, they attempt to change the speech without making changes in the way that the speech production system functions.

In contrast, other individuals may recover from stuttering because either consciously or subconsciously, they make changes in the way that the speech production system functions. These individuals introspect in an effort to discover what they are doing or thinking to create stuttered speech. They are focused on the process of speaking and make the changes necessary to generate fluent speech.

Here we will consider that an approach toward recovery that considers self-change as the key to success will improve therapy outcomes. We will examine the therapy process and identify what needs to be changed and what steps need to be taken to actually make the necessary changes. Instead of focusing on speech fluency, we will look at stuttered speech as one symptom of a dynamic speech production system that includes elements of speech-language planning and production that is in part driven by the thoughts, attitudes, and learned responses of the speaker (Dahm, 1997 ). We will explore whether changes in all these aspects of the system will lead to fluent speech and satisfaction with one’s ability to speak.

  1. Targets for change
When beginning the process of change, it is necessary to establish the targets of change. Since stuttering is a complex condition with a myriad of sym atoms, it is vital to attempt to identify the underlying cause of these symptoms, otherwise we run the risk of attempting to change symptoms while leaving their source intact. Although the cause of stuttering has not yet been determined, brain-imaging research has shown that it is not only the speech of people who stutter that is different. There are also brain processes that function differently during speech production. (Braun, 1997; Finitzo et al., 1991; Ingham et al., 1997). Watson and Freeman (1997) find that many brain-imaging studies merge into a coherent picture of a neuro-physiologic system that integrates cognitive, linguistic and speech motor process for the generation of fluent speech. Furthermore, they describe fluency as being “a reflection of the functional integrity and coordination of the components of the system” (p.158). Malfunctioning of the speech generating system would affect the fluency of speech. This perspective of stuttering supports the possibility that the focal point of treatment needs to involve making changes in the way the s oeech production system functions.

In order to understand the changes that have to be made to generate fluent speech, we need to consider how speech is normally produced. A model of normal speech production (Levelt, 1989) proposes that speech production Involves conceptualizing, grammatical and phonological encoding and motor execution along with a system of self-monitoring. The author argues that during speech production, conceptualizing requires conscious attention. However, the other components are largely automatic. “This automaticity (sic) makes it possible for them to work in parallel, which is a main condition for the generation of fluent speech.” (p.2).

Generating Fluent Speech: A Comprehensive Speech Processing Approach (GFS) is a treatment program that guides people who stutter to internally change the way they produce speech. Although fluent speech is the natural outcome of successful therapy, the goal of therapy does not focus on speech fluency. Treatment goals focus on changing the way that people who stutter carry out the same processes that Levelt includes in his model of speech production. (Figure l)


Figure 1. Comparison of the Levelt model of speech production to the speech processing goals of Generating Fluent Speech

The relationship between neural processing and stuttering has been consistently observed. However, stuttering should not be viewed only in terms of brain function. While the production of fluent speech is dependent on the processes used to produce speech, the processes used are driven by the speaker’s perceptions, thoughts, coping strategies, attitudes and beliefs concerning speech, stuttering, self and, in some cases, the nature of relationships with others. Affect and cognition have an impact on stuttering (Shapiro, 1999; Smith & Kelly, 1996). Lack of change in these areas prevents people who stutter from adopting new processes for the generation of speech.

  1. Complexity of change
Part of human nature is to resist change. Change may be threatening or simply uncomfortable. It may be exciting but, by it’s very nature, it is foreign. People may make a great effort not to change, because they view change as “putting on an act”. Some people who stutter may not accept the person that they hear when they speak fluently. While they want their speech to be fluent, they are not prepared for the feeling of fluency. They are not prepared to give up control. They are not prepared to accept the sound of their natural voice. They cannot let go of their fixation with words thereby allowing themselves to concentrate on ideas instead of words. They are not comfortable with the sensation experienced when they speak clearly. In short, it is difficult for them to accept the strangeness of their new way of speaking.

Changing behavior, cognition and affect does not happen because the individual wills it to happen. Change does not happen because the client entrusts himself to therapy administered by a qualified professional. Self-change is an active and internal process. The clinician can guide the client to set necessary goals for achieving desired results and support him through the treatment process, but it is the client who must actually take the steps that are necessary to bridge the gap between the setting of goals and achieving them. The process of self-change is not a simple one. Prochaska et al. (1994) report that 45% of patients drop out of psychotherapy prematurely. Nevertheless, change is not only possible; it is unavoidable. Living is dynamic and resisting all change is impossible. The purpose of treatment is, therefore, not to start a process of inevitable change, but to direct change to go ahead in the desired direction. ' 164 Theory, research and therapy in fluency disorders

  1. The goals of self-change
By setting goals the individual identifies the specific changes that are to be made. Clients who participate in Generating Fluent Speech learn to set goals that are incremental in nature. Importance-is given to smaller goals as well as major ones. Goals are structured so that it is clear when a goal has been achieved. All goals are formulated as a positive statement of What the individual will do. Too often people are aware of what they do not want to happen, but have not clearly identified how they can effectively shape the desired outcome. Goals must also be realistic. This means that a definite positive relationship must exist between the achievement of the goal and the desired outcome. If we are to assume that the desired outcome of treatment for stuttering is normally fluent speech, the goals that the person sets must realistically lead to this outcome. In Fig. l we have identified the speech processing goals that have been found to result in fluent speech that sounds normal (Dahm & Kaplan, 2000).


Figure 2. Examples of Generating Fluent Speech goals.

The fact that there is a cause and effect relationship between the process of speech production and the fluency of speech does not mean that the only important goals are specifically speech possessing goals. Establishing long-term change requires a two-pronged approach. One prong involves “planting”, cultivating cognitive and attitudinal change. The other involves “˜building”, constructing new behavioral patterns (Kelemen, 2001). Goals that relate to planting enable the individual to develop values and perspective that become internalized and eventually determine behavior. Building goals relate to learning and the acquisition 0" new behaviors. Generating Fluent Speech incorporates both planting and building goals. (Figure 2.) It focuses on developing the processes that are essential for generating fluent speech, establishing a belief system that supports these processes, and taking steps to internalize them until they become intuitive.

  1. The steps for making change
The steps for making change are the actions that are carried out in order to achieve goals. Each step in itself is part of the dynamic of change. Once a step is taken, no matter how small that step is a person will never be exactly the same. If other backward steps are later taken, even the subconscious memory of progress, brings about a new reality. There are many methods for affecting change. Freud (1916) believed in developing awareness of inner feelings, Perls (1978) focused on integrating awareness and behavior in the “here and now”. Ellis and Maclean (1998) proposed rational thinking. Another approach for working on change that was developed by Prochaska et al. (1994) is very direct, comprehensive and organized. The authors propose that there are six well- defined stages of change and explain that there are nine processes of change that enable people to move from one stage to the next. Each stage of change requires specific processes (Figure 3). Since this model of change can be applied to all issues, for the past year I have adopted it as part of the Generating Fluent Speech therapy program. Clients are guided to identify the stage of change that applies to them and to carry out the steps for change that relate to the processes appropriate for their stage. Moving from one stage to the other goes hand in hand with adopting a new way of generating speech.


Figure 3. Processes of change that are appropriate to the stages of change (Prochaska er al. 1994)

  1. Results of treatment
The subjects of this study were 30 clients ranging in age from 12-30 (mean 18.4) In order to assess whether treatment described here results in preferred client outcomes, clients were asked to rate their satisfaction in relationship to speech on Speech Satisfaction Scales (SPAT). This scale consists of 27 statements from the perspective of the client, that are rated by the client on 7-point scales (Figure 4). The statements were taken from 250 scalable statements discussed at the Fourth and Fifth Annual Leadership Conferences of The Special Interest Division - Fluency and Fluency Disorders. (Ratner & Quesel, 1998; Cooper, 1998) The 7-point scales were adopted in order to be consistent with ASHA’s N OMS’s procedures. Although these statements have not yet been validated as reliable functional fluency treatment outcome measures, it was suggested that they are an indication of change. They were, therefore, used to assess whether the goals of this treatment program resulted in change over a period of several months. The subjects were asked to rate themselves on SPAT on 4 occasions 1. Before treatment. 2. Immediately after three weeks of intensive treatmenz. 3. Between 2-3 months after treatment. 4. Between 5-6 months after treatment.

In addition, objective measures of speech fluency were obtained pre and post treatment. The entire Stuttering Severity Inventory-3 (Riley, 1994) was used in order to assess was the severity of stuttering. On this instrument the ratings range from very mild to very severe. In order to give a number Value we have labeled very mild=1; mild=2; moderate=3; severe=4; very severe=5; 0=below the very mild severity rating.


Figure 4. Speech Satisfaction Scales statements

Results of the SSI-3 show that the mean SSI severity scores for all clients before therapy was 3.27 with a standard deviation of 1.23. After therapy the mean SSI severity score for all clients was 0.70 with a standard deviation of 0.95. A t-test for the difference in the averages gives a sample t-statistic of t=12.7 (n=30), which is highly significant (p<0.0001). Figure 5 shows the individual scores of each client before and after therapy. For individual clients SSl-3 severity ratings show that after therapy 17 out of 30 clients were essentially fluent at the end of intensive therapy. An additional 7 clients were rated as 1=very mild stutterers; 4 clients were rated as 2=mild; 2 were rated as 3:moderate and none were rated as severe or very severe. This compared with before therapy ratings of 5 clients 5=very severe stutterers; 9 clients 4=severe; 8 clients 3=moderate; 5 clients 2=mild; 3 clients l=very mild.


Figure 5. Comparison of SSI-3 scores of individual clients before and after therapy


Table 1. Comparison of mean SPAT ratings after tx and after 3-4 and 5-6 months after Tx

Results of SPAT show that the mean scores of all clients changed before and after therapy. Before therapy the mean scores were 3.91. After therapy the mean score was 1.94. A t-test for the difference in the averages gives a t-statistic of t=l5.77 (n=30), which is highly significant (p<0.000l). Between 3-4 months after therapy the mean scores was 1.91. Between 5-6 months after therapy the mean scores was 1.87. When comparing mean scores after therapy and 5-6 months after therapy there is a mean difference of 0.065 with a standard error of 0.093. When comparing mean scores after therapy and 3-4 months after therapy there is a mean difference of 0.02 with a standard error of 0.698. Both differences are non-significant (refer to the t-test in Table 1; For example, for the two-sided test for 5-6 months after treatment, the significance level is 0.4908).

  1. Summary
SPAT statements have not yet been tested for validity in assessing preferred outcomes. Conclusive evidence of long-term change can only be made after validation of each individual statement on the rating scales is tested. Nevertheless, taken as a whole, these scales reflect aspects of speech satisfaction and a comparison of these ratings at different times could be considered as an indication of whether treatment results in the achievement of preferred outcomes. In this study we see that there was improvement in speech satisfaction ratings and that this improvement was maintained at least for six months.

Stuttering severity ratings before and after treatment and SPAT ratings over a period of six months indicate that it is possible that the targets of change and the processes used to bring about change in a treatment program designed to affect inner change in cognition, affect and the internal processes for generating speech do improve the outcome of therapy. The degree of improvement appears to surpass the assessment that one third of all clients make good improvement. Although etiology of stuttering cannot be ruled out as an indicator of success, the approach to recovery also appears to be an indicator of successful preferred client and clinical outcomes. Further study including assessment over a longer period of time would be beneficial to determine more fully the degree to which this treatment affects long-term change.

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I am indebted to Professor Haim Shore of Ben-Gurion University for his assistance with the statistical analysis.
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