"Dysphagia" Wha? -- Do Stuttering Therapists Need to Study the Full Speech-Language-Hearing Curriculum?

About the presenter: Darrell Dodge is a person who stutters who is a Masters degree candidate in Speech-Language Pathology at the University of Colorado at Boulder. He created and manages the National Stuttering Project's Web site; leads the NSP's Denver Chapter; and operates an Internet Web development and hosting business. He returned to school after a varied and successful 25-year career in advertising, technical editing, and research project management. A big inspiration for his career change was his speech therapy with Dr. Peter Ramig, a professor at CU. He holds an MA in English Literature from the University of Cincinnati, was awarded the American Wind Energy Association's "Federal Award" in 1996, and was named "Member of the Year" by the NSP in 1998.

"Dysphagia" Wha?

Do Stuttering Therapists Need to Study the Full Speech-Language-Hearing Curriculum?

by Darrell Dodge
Colorado, USA

There is a line of argument that, because stuttering seems to be totally different in many respects from other speech disorders, training for stuttering therapy doesn't need to be conducted as part of a complete speech-language and hearing curriculum. Some have gone so far as to say that stuttering is not really a speech disorder and that therapy should be taught as part of a psychology curriculum. While I've had some sympathy for the first viewpoint (though not the second) in the past, this diminishes as I progress through my graduate studies.

This argument is driven by the idea that requiring future stuttering therapists to learn all of the other speech disciplines in the course of obtaining competence in clinical practice is a waste of time and actually distracts them or dilutes their interest in their specialty. I have some sympathy with this view. Most graduate students can go through an entire SLH education with only one semester-long course in stuttering. Some manage to avoid stuttering coursework entirely. Meanwhile, the student interested in stuttering therapy will be required to take one or more courses in a variety of other areas such as phonology, motor-speech, voice, aural (hearing) rehabilitation, aphasia, cognitive disorders, learning-language disorders (child and adult), and augmentative and alternative communication. Because of the low incidence of stuttering (relative to, say, articulatory problems) and the appropriate definition of stuttering as a separate disorder with its own set of issues, stuttering is rarely even mentioned during many of these other courses.

Further, there are a number of ongoing debates about mismatches and omissions in the SLH curriculum. One of the most intense concerns Dysphagia, which - for those who may not have an unabridged dictionary handy - refers to a variety of swallowing disorders. There are many people in other speech-language areas who don't think swallowing problems caused by strokes, tumors, and other maladies should be the domain of speech-language pathologists at all. The argument for including them is that 1) they have at least some acquaintance with the anatomy and normal function of the mouth, throat, and the larynx, and 2) swallowing problems often co-occur with speech and language problems caused by strokes, traumatic brain injury, and various mouth and throat cancers. This makes eminent sense for an SLP in a hospital environment or for a voice therapist in private practice. But it doesn't seem very relevant for an SLP going into an elementary school-based practice, for example.

With the reality of a clinical specialty in stuttering therapy getting closer and closer (as a result of the ongoing work of ASHA's SID-4), and with a prevailing sympathy in some quarters for the viewpoints discussed above, there's liable to be a tendency to want to break stuttering therapy training away from the SLH core curriculum. This may even be intensified by the growing claims for the efficacy of therapy programs conducted by people with no formal training in speech-language science. For a variety of reasons, I think that this would be a grave mistake.

Beefing up the academic and clinical requirements for stuttering therapy training that actually involve stuttering would be highly welcome. But I'd like to say that - without question - every single course and line of inquiry I've undertaken in graduate school (including Dysphagia) has contributed to making me more knowledgeable about stuttering and a better stuttering therapist.

I've provided a discussion of some of my own reasons for thinking this way. It would be interesting to hear more about this - pro and con - from SLP's, teachers and students in SLH and other curricula, as well as from other people who stutter.

Knowledge About and Awareness of the Speech Mechanism

For anyone planning to specialize in stuttering therapy, it's absolutely essential to increase self-awareness of the speech mechanism. This is doubly important for a PWS going into therapy. One of the frustrating things about being a person who stutters is the relative lack of awareness humans have of their speech and vocal apparatus. To test this, please respond to the following commands: "Open your vocal folds. Now close your vocal folds."

Self awareness in this area is very difficult to attain unless there is a concerted objective effort to study the details of muscle innervation and action. Yet, such awareness is needed to counteract many stuttering secondary behaviors, which are sometimes consciously enacted by people who stutter based on incorrect notions about what makes the speech system work.

People who stutter have important questions about why they stutter. Some have heard or read things that have given them misleading impressions about the role of peripheral muscles or may develop ideas about the speech and hearing anatomy that inhibit their ability to make changes. Others may experience conditions (such as allergies) that make it more difficult to implement some fluency shaping techniques like gentle onsets. There is absolutely nothing wrong with the peripheral speech apparatus of people who stutter. By the same token, there is nothing intrinsic to laryngeal problems, cleft lips or palates, anatomical ear abnormalities (missing ears, ear infections, auditory nerve problems, etc.) or any other anomaly in this apparatus that would - by itself - have any effect on developmental stuttering. The only way to truly know this and be convincing about communicating it is to do the work of actually learning about these anomalies.

Understanding What Stuttering ISN'T

One of the most important insights the SLH curriculum provides is that stuttering (at least the developmental variety) is truly different from any other speech disorder. While a lot of this understanding comes from academic work, the actual observation of people with other speech disorders and syndromes - each of which has its own distinct characteristics - is what brings this home the best.

Importance of Speech Clinic Practica

A total 380 hours of Clinical practica - actual supervised therapy in various SLH areas - is a requirement of the full SLH curriculum. It is during these hours that the real differences between stuttering behavior and other speech disorders are seen in the sharpest relief. These hours also allow the increased sophistication of the "theory of mind" required to be a competent therapist of any kind. One's "theory of mind" is the understanding that other people have an entirely different set of assumptions, experiences, and capabilities. Interacting with many different people with different challenges - even within the set of behaviors called stuttering - provides the most useful insights of the SLH curriculum.

There was an actual statement by a person running an intensive, mass-attendance stuttering therapy "program" that some mistakes had been made in the first few years of the program that had eventually been corrected. Leaving out what these might have been, it is still the case that many hundreds of people were treated by a program acknowledged to be potentially damaging to them in some way. This should never be allowed to happen.

Knowledge of The Different Kinds of Stuttering

Developmental stuttering is only one type of stuttering with which speech-language pathologists will be confronted. Neurogenic and psychogenic stuttering are very different types of behaviors that are caused by different things (the first by actual brain damage, the second by a psychological reaction to a specific type of stimulus.) Differential diagnosis is important and difficult - particularly in the case of psychogenic forms or neurogenic stuttering with childhood onset. Treatment of neurogenic stuttering using some techniques designed for developmental stuttering could be psychologically damaging at worst and discounting or insulting at best.

Understanding the Pitfalls of Treating Co-Occurring Conditions and Stuttering

Really challenged children are faced with overcoming a phonological or articulation disorder as well as stuttering. But this is not the only condition that can co-occur with stuttering. Attention deficit disorders, Tourette Syndrome, Cerebral Palsy, cleft palate, and various learning and language delays and disorders can also co-occur with stuttering. In addition, there is the possibility of encountering conditions such as childhood neurogenic stuttering (from traumatic brain injury suffered in a fall, car crash, or child abuse ) and developmental apraxia of speech, which can look somewhat like developmental stuttering, but which may not respond to treatment in the same way or at all.

Providing therapy for a co-occurring articulation disorder or neurogenic voice disorder and stuttering requires great care, because the therapy techniques can be contradictory or can aggravate stuttering. Such cases are extremely common.

Arming the "BS" Detector

It's very easy even for experienced SLP's to get sucked into generalizations like "stuttering is associated with tension or blockage in the larynx (voice box)." This seemingly harmless statement carries a load of assumptions about what stuttering is and how it's caused. And, while the concept may be useful in some fluency shaping therapy, it is totally misleading to anyone who is trying to understand stuttering from the standpoint of modifying stuttering moments. For example, what does the concept of "blockage" really mean in the context of speech production? During one of the most dreaded stuttering events ("blocking" on the word "hello'), the stutterer's vocal folds may actually be fluttering around in an open position. How does one know that? By taking a course in Voice, during which one gains the insight that the rush of air that often escapes during some (not all) stutterers' "blocks" on "hello" can only mean that the vocal folds are "blocked" in an open position. The airflow is not "blocked," then. It's the activation of the larynx that's "blocked" - an entirely different thing. And something that's extremely useful to creating greater speech awareness.

Inoculation from Oversimplified Anatomical Theories

The SLH curriculum provides a unique, in-depth, functional understanding of the anatomy of speech and language from a variety of perspectives. Each division within SLH begins with a review of neuro-anatomy and - together with a required battery of psychology, neurology and anatomy courses - this provides information that can allow an informed understanding of the complexity of the human brain and its interaction with the peripheral muscles. Given this education, it is more possible to resist explanations of stuttering that require the brain to work in simplified or magical ways that are conveniently within the theorist's grasp.

There are theories around that stuttering is caused by cortical inefficiency, bimodal innervation of the diaphragm, auditory processing or feedback delays, focal laryngeal tension, faulty language processing, an over-abundance or relative lack of various brain wave forms, unspecified neurological flaws or defects, and excess amounts of neurotransmitters. There are other theories that totally discount conditioned learning or that totally ignore the physical basis of brain activity. And there are still many people who think in dualistic terms about "nature-nurture," "physical-mental," and other dichotomies.

The key here is not to understand fully what causes stuttering, but just to be aware when a theory seems a bit to simple or limited to sound believable.

Problem Areas

There are definite problems that arise from including stuttering in the SLH curriculum. I think these problems can be solved by improving or extending the curriculum, and don't mean that stuttering should be moved elsewhere.

One of the biggest problems is the tendency to define stuttering in terms of one or more language, voice, or hearing disorders. It is very easy for this to occur when there is incomplete knowledge of other speech-language disorders or when someone defines all speech-language disorders in terms of one discipline. In stuttering, this tends to happen with language and voice. It may be easier to fall into this trap when the student lacks the internal mental and sensory knowledge of stuttering possessed by a person with the disorder.

Yet another shortcoming is the lack of adequate counseling education in the curriculum. There are apparently only 25 SLH graduate schools in the U.S. that include a counseling course as a required part of their curriculum. Others, like my school (the University of Colorado at Boulder), provide a Clinical Theory and Practice course that touches on counseling, include information on counseling in all of their courses, and require clinical supervisors to provide counseling guidance and training for students during clinical practica. But most graduating SLP's will have to obtain additional counseling training to obtain a counseling license, where that is required.

Finally, there is the insularity of the SLH curriculum (in every major area but one). I think this insularity has been set up by a desire to protect stuttering education and therapy from specialists in other areas who may have uninformed - and potentially damaging - opinions about stuttering. But it's also meant that stuttering researchers have generally not attempted to apply recent insights about emotion and learning. The one major area where collaboration has occurred is brain imaging. Unfortunately, this has meant that insights from other fields are limited to snapshots of phenomena, without any real investigation or understanding of cognitive or emotional processes or dynamics that is required to interpret the images.

I invite comments and questions and the thoughts and ideas expressed in this brief article. I hope it has been clear that I don't feel that simply going through a graduate program will ever make anyone a competent therapist of any kind. The point is that people receiving stuttering therapy - a process that requires a significant investment of time, money, personal effort, and a major life change - should at least expect the person working with them to have made a similar specific investment in preparing him/herself to provide therapy services.

September 14, 1998