copyright 2010 delmar, a part of cengage learning. all rights reserved. 1 successful management of...

1Copyright 2010 Delmar, a part of Cengage Learning. ALL RIGHTS RESERVED.

Successful Management of Successful Management of Stuttering for Adolescents Stuttering for Adolescents

and Adultsand Adults

CHAPTERCHAPTER 88


• Increasing fluencyIncreasing fluency• Improving communication Improving communication • Developing greater autonomy Developing greater autonomy (agency)(agency)

Remember these goals?Remember these goals?


Some principles of changeSome principles of change

• More Toward Rather than Away from the More Toward Rather than Away from the ProblemProblem

• Assume the Responsibility for Taking Action Assume the Responsibility for Taking Action (practice & becoming one with techniques)(practice & becoming one with techniques)

• Restructure the Cognitive View of the Self and Restructure the Cognitive View of the Self and the Problemthe Problem

• Recruit the Support of OthersRecruit the Support of Others


Understanding: The essential Understanding: The essential structure of structure of unsuccessfulunsuccessful stuttering stuttering

management *management *

The experience of stuttering may be characterized The experience of stuttering may be characterized by a story dominated by by a story dominated by struggle and sufferingstruggle and suffering. . Struggling to cope with the difficulties posed by the Struggling to cope with the difficulties posed by the problem of stuttering, persons who stutter tend to problem of stuttering, persons who stutter tend to lead a lead a restrictive lifestylerestrictive lifestyle dominated by attempts to dominated by attempts to avoid avoid stuttering and to avoid revealing their stuttering and to avoid revealing their stuttering to the world. These struggles, along with stuttering to the world. These struggles, along with negative reactions from a variety of listeners, negative reactions from a variety of listeners, including family members, and failureincluding family members, and failure


Understanding: The essential Understanding: The essential structure of structure of unsuccessfulunsuccessful stuttering stuttering

management * (continued)management * (continued)

failure associated with inadequate therapy can failure associated with inadequate therapy can lead to emotions of helplessness, anxiety, low self lead to emotions of helplessness, anxiety, low self worth, embarrassment, and disapproval and an worth, embarrassment, and disapproval and an overall life tenor of suffering. overall life tenor of suffering.

* Plexico, L., Manning, W., & DiLollo, A. (2005). A * Plexico, L., Manning, W., & DiLollo, A. (2005). A phenomenological understanding of successful stuttering phenomenological understanding of successful stuttering management, management, Journal of Fluency DisordersJournal of Fluency Disorders, 30 (1) 1-22., 30 (1) 1-22.


Understanding: The essential Understanding: The essential structure of structure of successfulsuccessful stuttering stuttering

management management

Successful management of stuttering is Successful management of stuttering is

characterized by an characterized by an optimistic and positive optimistic and positive

interpretationinterpretation of life. In spite of the fact that self of life. In spite of the fact that self

management of stuttering continues, the management of stuttering continues, the

possibility of stuttering is possibility of stuttering is no longer a major no longer a major

themetheme. There is a sense of appreciation for what . There is a sense of appreciation for what

has been accomplished. Although speakers are has been accomplished. Although speakers are

considerably more fluent than in the past, moreconsiderably more fluent than in the past, more


Understanding: The essential Understanding: The essential structure of structure of successfulsuccessful stuttering stuttering

management (continued)management (continued)fluent than in the past, more dominant themes fluent than in the past, more dominant themes indicate that life choices are indicate that life choices are no longer restrictedno longer restricted by by anxiety anxiety or or fearfear associated with stuttering or the associated with stuttering or the possibility of stuttering. There is an obvious sense possibility of stuttering. There is an obvious sense of of freedom to act and speak on one’s own behalffreedom to act and speak on one’s own behalf..

Plexico, L., Manning, W., & DiLollo, A. (2005). A Plexico, L., Manning, W., & DiLollo, A. (2005). A phenomenological understanding of successful stuttering phenomenological understanding of successful stuttering management, management, Journal of Fluency DisordersJournal of Fluency Disorders, 30 (1) 1-22., 30 (1) 1-22.


Transitional themesTransitional themes(Plexico, et al. 2005)(Plexico, et al. 2005)

Support from othersSupport from others

Successful treatment Successful treatment

(No specific techniques or protocols)(No specific techniques or protocols)

Self-therapy & behavioral changeSelf-therapy & behavioral change

Cognitive changeCognitive change

(taking risks/disclosing stuttering)(taking risks/disclosing stuttering)

The development of counterplotsThe development of counterplots

Motivation & persistenceMotivation & persistence


Basic stuttering modification Basic stuttering modification strategiesstrategies

• Aka Non-avoidance/Van RiperianAka Non-avoidance/Van Riperian

• My experience with this approachMy experience with this approach

• How to stutter easier & betterHow to stutter easier & better

• Deals with fear, avoidance, & struggleDeals with fear, avoidance, & struggle


It requires the speaker to . . .It requires the speaker to . . .

• Stay in the moment of stutteringStay in the moment of stuttering• e.g., “freezing”e.g., “freezing”

• Requires (some) desensitizationRequires (some) desensitization

• Learn to play with the behaviors and Learn to play with the behaviors and attitudes (Jeff in VR tape)attitudes (Jeff in VR tape)


Goals of stuttering modificationGoals of stuttering modification

• Doing more than creating Doing more than creating easyeasy stuttering stuttering——greater fluency greater fluency isis a realistic goal a realistic goal

• Changing behavior & Changing behavior & decisions about decisions about communicatingcommunicating

• Dealing with helplessness and taking charge of Dealing with helplessness and taking charge of stuttering eventsstuttering events


A few problemsA few problems

• More difficult to teachMore difficult to teach——many counseling many counseling componentscomponents

• Clinician must demonstrate & role playClinician must demonstrate & role play

• Involves more cognitive response than many Involves more cognitive response than many fluency-shaping approachesfluency-shaping approaches


Stages of stuttering modificationStages of stuttering modification

• IdentificationIdentification——acceptance and explorationacceptance and exploration

• DesensitizationDesensitization——staying in the moment, staying in the moment, considering optionsconsidering options

• VariationVariation——experiment & play with behaviorexperiment & play with behavior

• ModificationModification——before, during, afterbefore, during, after

• StabilizationStabilization——practicepractice


Modification techniquesModification techniques

• PostPost Stuttering Stuttering——CancellationCancellation

• DuringDuring Stuttering Stuttering——Pull outPull out

• BeforeBefore Stuttering Stuttering——Prep SetPrep Set

• Video examples to followVideo examples to follow

• Note:Note: doing this to doing this to take chargetake charge——not to achieve not to achieve fluency, particularly at the outsetfluency, particularly at the outset


Steps of cancellationSteps of cancellation

• Stop after event (~ 3 s)Stop after event (~ 3 s)

• Analyze old stutteringAnalyze old stuttering

• Pantomime easier/smoother formPantomime easier/smoother form

• Incorporates fluency shaping targetsIncorporates fluency shaping targets

• Last chance to catch old stutteringLast chance to catch old stuttering

• Must be desensitized Must be desensitized

• Takes Takes muchmuch practice practice


The basics of fluency shapingThe basics of fluency shaping

• A history of behavioral modificationA history of behavioral modification• Create & expand fluent speechCreate & expand fluent speech• Increase length & complexityIncrease length & complexity• Little focus on deep structure of changeLittle focus on deep structure of change• Tends to work well with young childrenTends to work well with young children• Often works well during the later stages of Often works well during the later stages of

stuttering modificationstuttering modification


Fluency shaping targetsFluency shaping targets

• Slow rate (one syllable/second)Slow rate (one syllable/second)

• Full breathFull breath

• Continuous airflowContinuous airflow

• Gradual onset of phonationGradual onset of phonation

• Continuous voicing Continuous voicing

• Easy articulatory contactsEasy articulatory contacts

• Blending of all sounds & syllables (within & between Blending of all sounds & syllables (within & between words)words)


All techniques All techniques ––

Require a lot of practiceRequire a lot of practice

Are often nonintuitiveAre often nonintuitive


ConclusionConclusion

• Fluency shaping for young childrenFluency shaping for young children

• Most adolescents and adults need Most adolescents and adults need bothboth stuttering stuttering

-modification and fluency-shaping techniques -modification and fluency-shaping techniques

• Depends on what client needs from us and is Depends on what client needs from us and is

capable of and willing to docapable of and willing to do


Adolescents can be difficult cases Adolescents can be difficult cases because . . .because . . .

• Many other interests, Tx likely a low priorityMany other interests, Tx likely a low priority

• The hope that stuttering will go awayThe hope that stuttering will go away

• Schooling often increases handicapSchooling often increases handicap

• Avoidance & substitution increaseAvoidance & substitution increase

• May be a history of negative reactionsMay be a history of negative reactions• To fluency failureTo fluency failure• To teasingTo teasing• To treatmentTo treatment


And it also requires . . .And it also requires . . .

• involvement of the familyinvolvement of the family

• dependence on an adultdependence on an adult

• development of a trusting clinical relationship development of a trusting clinical relationship with a with a female female clinicianclinician

• hard work for months or yearshard work for months or years

• lots of practice! lots of practice!


Basic messages to an adolescentBasic messages to an adolescent

• Success IS possible!Success IS possible!

• Stuttering is no one’s faultStuttering is no one’s fault

• A successful future is possibleA successful future is possible

• Good clinicians are available to helpGood clinicians are available to help

• You are not aloneYou are not alone• Stuttering Home PageStuttering Home Page• National Stuttering AssociationNational Stuttering Association• Stuttering FoundationStuttering Foundation


The appeal of a PCT approach to The appeal of a PCT approach to interventionintervention

From a Constructivist-Narrative Perspective:From a Constructivist-Narrative Perspective:

Perry, A., & Doan, R. E. (1994). Perry, A., & Doan, R. E. (1994). Story Re-Story Re-Visions Narrative Therapy in the Postmodern Visions Narrative Therapy in the Postmodern WorldWorld. New York, NY: The Guilford Press.. New York, NY: The Guilford Press.


A narrative approach is . . .A narrative approach is . . .

• Not dogmaticNot dogmatic• No single approach or techniqueNo single approach or technique

• Process is driven by the person’s storyProcess is driven by the person’s story • Places the client in key role; de-centralizes the clinician Places the client in key role; de-centralizes the clinician

as an authorityas an authority• We are in the role of an We are in the role of an editoreditor with the with the client as the client as the

lead authorlead author

• OptimisticOptimistic——assumes that people can take action to assumes that people can take action to rewrite their narrativesrewrite their narratives

• Sees the person as a courageous victor rather than a Sees the person as a courageous victor rather than a pathologized victimpathologized victim


Narrative guidelines Narrative guidelines (5 of 13 by Perry & Doan)(5 of 13 by Perry & Doan)

1. Be Curious1. Be Curious

• Know little but be curious about everythingKnow little but be curious about everything

• Being bored is a sure sign of a lack of curiosityBeing bored is a sure sign of a lack of curiosity

2. Go with the client’s resistance2. Go with the client’s resistance• Our oppositional stance escalates client’s Our oppositional stance escalates client’s

resistanceresistance

• More resistance when editing from “expert” statusMore resistance when editing from “expert” status


Narrative guidelines (continued)Narrative guidelines (continued)

3. Watch for Client Strengths 3. Watch for Client Strengths

• Cues of successful authorship Cues of successful authorship

• Cues of unique outcomesCues of unique outcomes

• Solution-focused themes rather than problem-Solution-focused themes rather than problem-saturated themessaturated themes

4. Expand the Focus of Treatment4. Expand the Focus of Treatment

• Look beyond the basic symptoms/behaviorsLook beyond the basic symptoms/behaviors

• Consider historical backgrounds: culture, Consider historical backgrounds: culture, gender, religion, family, ethnic heritage.gender, religion, family, ethnic heritage.


Narrative guidelines (continued)Narrative guidelines (continued)

5. Do not work harder than your client5. Do not work harder than your client

• The more the clinician (or parent) works the The more the clinician (or parent) works the less the client (or child) is invited to participate. less the client (or child) is invited to participate.

• The more responsible the clinician the less The more responsible the clinician the less responsible the client.responsible the client.

• ““Working Harder than My Clients” is an Working Harder than My Clients” is an excellent title for a book whose final chapter will excellent title for a book whose final chapter will be “Burned Out.”be “Burned Out.”

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