What Is "Successful" Stuttering Therapy

About the presenter: Robert W. Quesal, Ph.D. is an associate professor at Western Illinois University, where he serves as program director and graduate advisor. He received his bachelor's and master's degrees from Indiana University-Bloomington and his doctorate from the University of Iowa. Before coming to Western Illinois University, he was on the faculty at the University of North Dakota from 1983-1986 and the State University of New York-Plattsburgh from 1986-1991. He teaches courses in fluency disorders, anatomy, and speech and hearing science. He has presented at regional, national, and international meetings. His chapter entitled "Knowledge, Understanding, and Acceptance" was recently published in the Stuttering Foundation of America publication "Advice to Those Who Stutter." He has served as newsletter editor for ASHA's Special Interest Division 4-Fluency & Fluency Disorders since 1997. He has been listowner of the STUT-HLP listserv since June of 1993, and also serves as list manager for the listservs for ASHA's Special Interest Division 4 and Special Interest Division 10-Issues in Higher Education.

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What is "Successful" Stuttering Therapy?

by Bob Quesal
Western Illinois University
Macomb, IL USA

• Is therapy for stuttering generally "successful?"
• Are people who stutter generally "helped" by therapy?
• Is an individual’s speech "better" after therapy than it was before therapy?
• Is most stuttering therapy "good" or "bad?"
• Who determines whether therapy has been "successful?"

Many individuals think of "successful" stuttering therapy as therapy that leads to normal levels of fluency. In this paper, I will argue that there is more to "success" in therapy than simply a change in fluency.

The motivation for this essay comes from some recent developments in the American Speech-Language-Hearing Association’s Special Interest Division 4–Fluency and Fluency Disorders, as well as some recent discussions on the STUTT-L listserv. The past two leadership conferences held by Division 4 have focused on "outcomes" of stuttering therapy. In 1997, the conferees gathered to develop "outcome statements" from a number of perspectives: i.e., the client, the clinician, the family, society, insurance companies. The goal of the 1998 leadership conference was to take those statements from 1997 and develop them into 7-point scales that could be used to measure "functional outcomes" of stuttering therapy.

I was involved in both of those conferences. When we broke into small groups during these meetings, the people in the groups that I was a part of all seemed to understand that we needed to look at more than just fluency if we were to determine "functional outcomes." To my way of thinking, improved fluency as a desired outcome of treatment is a foregone conclusion. It seems that there is no question that the "most desired" outcome of therapy is fluent speech. Ideally, this speech is "normally fluent" in the sense that the speaker can talk whenever and wherever he or she chooses, with essentially no effort, little anxiety, in a manner that is acceptable to the speaker, and that sounds "natural" to the listener.

Ideals, unfortunately, cannot always be achieved. In my experience as a stutterer and speech-language pathologist, I have come to realize that for many stutterers "normal" fluency is an unattainable goal. This is not to suggest that I do not believe that some individuals who stutter are capable of achieving high levels of fluency, or even normal fluency. I do not believe, however, that all stutterers are capable of this. In my opinion, it was for this group of individuals—those for whom "normal" fluency is not a realistic goal—that the preponderance of the outcome statements evolved.

During (and perhaps even more following) the 1998 leadership conference, during which we attempted to take the "outcome statements" from 1997 and develop them into 7-point scale items, there arose a bit of an outcry. In the August 1998 issue of the Special Interest Division 4 newsletter, Cordes, Finn, Ingham and Packman wrote about their "reflections" on the Leadership Conference, as did Shenker, Kully, and Meltzer. Among the criticisms leveled by Cordes, et al. was the following: "If we continue our present course, though, it appears that before too long our assessment and outcomes measures for stuttering will have much more to do with convincing our clients to report that they feel generally happy about themselves and will have much less to do with assessing the occurrence or the severity of stuttering. Before too long, we will have created a system in which stutterers will still be receiving treatments that do nothing for their stuttering, but clinicians will be able to document that they are doing a great job or producing well rounded human beings who have moved from 4 to 6 on an outcome scale, and who now talk whenever they feel like it." (p. 8) Shenker, et al. said: "Although measures of satisfaction may provide important information, they do not tell us whether the client actually improved. …it concerns us that in our meeting in Florida, many seemed to have lost sight of the fact that as speech-language pathologists, our first responsibility to the client should be the rapid reduction in stuttered disfluencies…. While we wholeheartedly agree that successful therapy must integrate aspects of cognitive and affective change, we feel that, given the choice, most stutterers initially come to therapy to reduce stuttering behaviors. If we hold the view that treatments should be client-focused and address the primary source of complaint, then objective measures of stuttering behavior [emphasis added] must occupy a central role in outcomes measurement." (p. 10)

It might be useful to review some of the outcome statements that came out of the 1997 Leadership Conference, since these are the statements upon which the 7-point scales were to be based. The selected statements below come from the report on the 1997 conference (Bernstein Ratner and Quesal, 1998). I have chosen to review the outcomes that were intended to present the clinician’s point of view and the client’s point of view. (A full copy of the outcome statements is available on request.)

Preferred clinical outcomes: The preferred treatment outcome relative to the clinician is that the client will demonstrate feelings, behaviors, and thinking that lead to improved communicative performance and satisfaction with the therapy process.

These outcomes can be operationally defined to include the following:

• Frequency and/or severity (duration, tension, evident struggle) of stuttering is reduced in variety of settings.
• Speech sounds natural (intonation, loudness, rate) in variety of settings.
• Speech fluency has increased.
• Client has increased volitional communication.
• Client is able to use techniques independently in a variety of settings.
• Avoidance behaviors have been reduced.
• Client has increased knowledge and understanding of speech and stuttering.

Preferred client outcomes: As a result of therapy, the client should be able to positively rate the following outcomes:

• I am satisfied with my therapy program and its outcome.
• My client/clinician jointly determined goals were met.
• I have an increased ability to communicate effectively.
• I feel more comfortable as a speaker.
• I like the way I sound.
• I have an increased sense of control over speech, including stuttering.
• My speech has become more fluent.
• I am independently able to employ a variety of techniques and strategies as appropriate.
• My understanding of stuttering and fluency has increased.
• My speaking skills have become more automatic.
• I have an increased ability to cope with variability of stuttering and relapse.
• I am better able to reach social/educational/vocational potential and goals.

(These outcome statements presume an adult client. Though time did not permit formal discussion, it was recognized that outcomes for therapy provided to children would have to be adjusted to reflect their particular concerns, and those of their parents).

It is difficult for me to see why these types of outcome statements are so troublesome. In my opinion, they address the realities of stuttering and stuttering therapy. In my experience, many individuals are unable to achieve "normal" levels of fluency, and many are unable to do so "rapidly." The fluency I’m talking about here is day-to-day fluency, not a flight into fluency experienced by choral reading, talking with the beat of a metronome, talking under DAF, or using some sort of exaggerated way of talking. If an individual does not achieve high levels of fluency during treatment, has the client or his clinician failed? Is fluency the only measure of success in treatment? I certainly hope not.

The fluency that is "natural" for a particular speaker is based upon many factors. A person has basic speech motor skills and linguistic skills, and these combine with experiences, skills learned in therapy (or, in some cases artifacts of previous therapy), "coping behaviors" that have been developed over a long period of time, self-perceptions and many other factors that make each person unique. To suggest that all stutterers are capable of normally fluent speech is an insult to those of us who have worked for years to be effective communicators, but who still are not highly fluent speakers. It is interesting, too, that in most cases people who hold the goal of normal fluency (or high levels of fluency) as the goal for stuttering therapy tend to be individuals who do not stutter. I suppose it should not be surprising that the average person on the street feels that all stutterers should be able to talk fluently if "they just tried hard enough." It’s a bit more troubling when this attitude seems to be held by some of my professional colleagues who are experts in stuttering. It’s even more troubling when this attitude is expressed, implicitly or explicitly, to individuals who stutter.

Let me reemphasize here that I am not saying that we should enter the therapeutic relationship with the attitude that an individual who stutters is incapable of fluent speech and therefore we do not address speech fluency. I am suggesting that while we address fluency, there are many other factors to consider.

How do I define "success?"

I submit that stuttering therapy can be deemed "successful" if it leads to the following:

• A change in speech fluency. High levels of fluency and "normal" fluency are always desired. If an individual cannot reach these levels, however, it does not mean that therapy has not been successful. For many individuals, a change in fluency does not mean normal fluency, nor does it necessarily mean low levels of disfluency. It means that the individual who has been in therapy has learned a different, more effective way of talking for him/her. The successful individual has learned about his or her speech, how it varies, factors that affect fluency and disfluency, and strives to be the best speaker and most effective communicator that he or she is capable of being.
• A reduced impact of stuttering on an individual’s life. This impact may be reflected in the way an individual goes about his or her day-to-day activities, vocation, social life, etc. A "successful" individual does not let stuttering play a major role in life decisions.
• Finally, a successful individual has an increased acceptance of stuttering. Stated broadly, acceptance would be the context in which a stutterer views his or her speech and abilities as a speaker. The individual no longer chases the "fluency god," but instead is able to accept that he or she has done all that can be done to speak as well as possible. Slight disfluencies do not concern the successful individual. The successful individual can work through most disfluencies, but realizes that occasionally speech will be difficult. An individual who accepts stuttering can talk about it with others. He or she views stuttering as a personal characteristic, similar to height, athletic ability, complexion, sense of humor, reading and writing skills, and any other number of things that make us who we are.

Am I taking the easy way out here? I don’t believe so. I feel that these less tangible aspects of stuttering are what make it such a complex, challenging disorder both for people who stutter and for the professionals who treat stutterers. We cannot say that therapy is successful only if a client is fluent following that therapy. I feel that Special Interest Division 4 should be given credit for viewing stuttering and therapy outcomes in this broader way. I do not think anyone is giving up on fluency as a goal. However, we can help people who stutter in many, many other ways. "Successful" treatment addresses the totality of stuttering. Our outcome measures should do the same.

References

Cordes, A., Finn, P., Ingham, R., and Packman, A. (1998). Reflections on the 1998 Division 4 Meeting. American Speech-Language-Hearing Association Special Interest Division 4, Fluency & Fluency Disorders newsletter, 8 (3), 7-9.

Ratner, N. B., and Quesal, B. (1998). Report on the 1997 Leadership Conference in Tucson. American Speech-Language-Hearing Association Special Interest Division 4, Fluency & Fluency Disorders newsletter, 8 (1), 6-7.

Shenker, R.C., Kully, D., and Meltzer, A. (1998). Letter to the Editor Concerning the Leadership Conference. American Speech-Language-Hearing Association Special Interest Division 4, Fluency & Fluency Disorders newsletter, 8 (3), 9-10.

(This paper was based, in part, on a presentation by my former student and current professional colleague Annette Teslik and me at the 1998 Illinois Speech-Language-Hearing Association Convention, entitled "‘Successful" stuttering therapy: An in-depth case study." Thanks to Annette for her input on this paper.)

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August 24, 1998