Creating Your Own Map for Change
About the presenter: Walt is a professor and Associate Dean in the School of Audiology and Speech-Language Pathology at The University of Memphis. He received his bachelors degree from Lycoming College in Pennsylvania in 1964, his masters degree from Penn State University in 967, and his doctorate from Michigan State University in 1972. He served on the faculty of the University of Nebraska from 1972 to 1977. At the University of Memphis he teaches courses in fluency disorders and research methods. He has published more than 60 articles in a variety of professional journals and has presented on many occasions to regional, national, and international meetings. He is a member of the Steering Committee of ASHA's Special Interest Division 4 [Fluency & Fluency Disorders], serves a reviewer for several journals and is currently an Associate Editor for the Journal of Fluency Disorders. In 1996 he completed a text titled "Clinical decision making in the diagnosis and treatment of fluency disorders" published by Delmar Publishers Albany, NY. He has served several positions in the Tennessee Association of Audiologists and Speech-Language Pathologists including Vice President for Planning and President. He is a fellow of ASHA and has received the honors of Tennessee Association of Audiologists and Speech-Language Pathologists.
CREATING YOUR OWN MAP FOR CHANGE
by Walter Manning
from Tennessee, USA
Change Happens!
For more than 25 years I have tried to help children and adults who stutter, I have seen many people make big changes in their speech fluency. More important, I've seen people who stutter make important changes in their lives. I don't think that you can do one without doing the other. When you change your response to the stuttering experience, you also change the way you see yourself and the way you see others. You may begin to consider choices you never allowed yourself to take seriously before - like giving a speech or being in a play. You push and stretch the envelope of your life and as a result you often end up having some great adventures. In a little while I'll mention some specific indicators of change and progress. But the basic message I'd like to get across at the outset is that I believe that progress is possible whether you are able to obtain professional help or you are on your own.
Changing is Difficult
Having said that, I also need to say that the process of change is difficult. It can be frustrating and it usually takes a long time. Also, the process of change is not linear. By that I mean that we change in cycles. We lose some weight, we get in a little better shape and then we fall back a bit -- or maybe a lot. Changing stuttering is like that. If you have been living with stuttering for decades there are many things that need to change -- not just the frequency of your getting stuck - in order for your situation to get better. Changing stuttering involves so much more than just changing speech as difficult as that is. There is inertia to be overcome in the form of expectations about yourself, both your own expectations and the expectations of others. You have lived and survived in the culture of stuttering by doing things such as avoiding sounds, words, people, and places. You are likely to have substituted words, used starter sounds and phrases, and developed ways of doing things that provided some form of protection from the penalties that go along with being a person who stutters. You do what you can to avoid "the look". You may have limited your options to the point where you no longer even consider some choices. You make decisions about what to say, what to do (or not do) based on even the possibility of stuttering.
It usually takes some time to change all the multidimensional aspects of stuttering. I think the core of any good treatment program has a strong counseling component. The process of change for someone who has stuttered for many years, whether in the context of formal treatment or informal self-therapy, is rarely as simple as decreasing the frequency of the stuttering events.
Changing Stuttering without a Coach
One other thing I must say at the outset is that I believe that both likelihood of change will be increased and the quality of change will be enhanced with the help of a good speech language pathologist. This is a difficult race to run without a coach. I recognize that finding a clinician, especially a good one, is not easy. We could talk for a long time about what a good clinician might be. I have no doubt that there are people in this audience who can tell us about the characteristics of a poor clinician.
I have some thoughts about what constitutes a good clinician and I won't go into great detail here today although I do discuss this at some length in the first chapter of my text. I will say that a really good clinician could be characterized as being enthusiastic, genuine, empathetic and demanding. I mention enthusiasm because that may be the most important characteristic for anyone who is doing anything. I mention demanding because sometimes the clinician, like a coach or a parent, has the responsibility to push the person to places he or she didn't know about or didn't imagine he could go. Sometimes he or she has to be the bad guy and push us to do things we wouldn't do on our own.
A good clinician has a map of the territory, knows the surface features of stuttering, understands the levels of the handicap beneath the surface, and has a good sense of direction when it comes to the treatment process. Having an experienced guide is always a good idea when you are exploring new, and maybe scary, territory. A good clinician will be able to lead the way and model the attitudes and behaviors that are essential for progress.
Finally, a good clinician is a good listener. As Carl Rogers said years ago, having someone who believes that you and your story are important is a fundamental part of the therapeutic process. Acceptance by a clinician can lead to acceptance of yourself and your problem. Once you have acceptance, you can begin to take action.
You may be interested to know that in the United States, we have recently created a specialty recognition program for clinicians working with people who stutter. Created within the American Speech-Language-Hearing Association's Special Interest Division for Fluency and Fluency Disorders (Division 4), this procedure verifies those clinicians with special interest and preparation for working with people who stutter. After many years of preparation, the initial group of clinicians who will be recognized in this way are now being identified. We believe that this process will help consumers to select clinicians who are dedicated to and focused on helping people who stutter.
Accepting Yourself
As I mentioned, accepting the fact that you really do stutter is an essential first step in the process of change. When you are young you always have in the back of your mind the thought, the hope, that your stuttering will go away. Sometimes, as the literature on recovery indicates, that does occur. But most of the time it doesn't. Sometime around your early twenties you may realize that you are always going to be someone who stutters. That is a time when many people seek help. Either by yourself, or with the assistance of a clinician and maybe a support group, you stop spending so much effort hiding the fact that you stutter. You may go a step further and stop trying so hard not to stutter. You might even find that there are easier, even pleasing ways to stutter.
Therapy Is Multidimentional
Anyone who suggests that stuttering is a unidimensional problem or that treatment for stuttering is simplistic, is someone to stay clear of. In my opinion, people who suggest on the phone or on their web page that they have the answer, especially if they provide testimonials by several clients who are now as fluent as some anchor person on the national news, should definitely be avoided.
I will agree that a clinician can sometimes use a reasonably basic and straight-forward treatment strategy that will work quite nicely if the client is unencumbered by a lot of anxiety, shame, and embarrassment about stuttering. Being a clinician is sometimes like coaching. When the game is an easy one and the opponent is not particularly difficult, you don't have to be a great coach to achieve success. Success probably means that you are a great recruiter, not necessarily a great coach. It's like Joe Paterno coaching the Penn State football team when they play one of their early season games against a school called Our Lady of Perpetual Losses. You draw up a game plan and pretty much go out and do it.
It's only when things aren't going so well and you're behind half way through the contest that you find out how good the coach really is. A good coach figures out what adjustments need to be made. He or she identifies how to exploit the other team's tendencies and weakness and how to come up with a new plan. A good coach (or clinician) is able to make decisions in the moment when there is pressure and when there is a clear risk of being wrong. How the team does in the second half tells you a lot more about how good the coach is. And along with being a great recruiter, Joe Paterno is a great coach who has done that many times.
Getting Ready to Run the Race
Whether you are involved in formal treatment or are making the changes on your own, at some point you have to decide if you are ready to run the race. Along with acceptance of yourself and your problem, motivation to change is important. Charles Van Riper often said that motivation is everything. I do know that motivation is not what you say, it's what you do. In that sense, the clinical relationship is like any relationship; it's not so much what you say; what really counts is what you do.
I've been fooled by many clients who have convinced me that they were ready to begin the race. But when it came time for the discipline and rigor of running the laps, they were not ready. Maybe I hadn't adequately prepared them. Maybe the timing wasn't right and they weren't yet desperate enough. It's always good, I think, to ask people why they come to see us when they do. Why today and not a year ago? Or six months from now? What is it about this particular time that causes you to ask for help? There are good answers and there are better answers. Is it a temporary crisis or is it a more basic life decision? I prefer to have clients who are desperate to change rather than those who are faced with a temporary crisis.
If there is an advantage of self therapy it may be that you are able to select the strategy and the techniques that are congruent with your present needs and your personality. That in itself can be motivating. But don't search for "the method" or "the technique". Following one book tends to shut out other possibilities. And don't search for a single answer that will result in perfect fluency. Chasing the "Fluency God" leads to frustration and anger. It's better to do the work of achieving improved communication. It is possible to stutter and be a very good communicator.
PRIME DIRECTIVES FOR CHANGE
1. Do not avoid - at least not much
I paddled a kayak for about twelve years and often I wish that I still did. Surfing a wave on a beautiful white water stream is a grand place to be. At the time I began kayaking I had been stuttering for nearly four decades. As I slowly gained experience on different rivers I began to realize that there were some remarkable similarities between kayaking and stuttering. For those of us who stutter it's not a great leap to appreciate how loosing control in some big, scary rapids is comparable to a speaker who feels they are drowning in the stream of speech. Not all stuttering moments are colored by this loss of control. But when it occurs, it's sudden and complete. At the center of the experience is a sense of helplessness.
One of the common events when paddling in white water is the experience of encountering a large rock or a wave that rolls back on itself (called a hydraulic). If you are new to paddling you instinctively want to move away from these obstacles. You don't care how you escape but you feel that you must. Of course, in many cases you simply can't avoid the barriers. As a novice approaching the threat, your instinct is to lean away from the problem. But you quickly learn that as you lean back upstream to avoid the problem, you will immediately find yourself upside down. This is where a good coach can help. With proper instruction and experience, you'll discover something that's both subtle and amazing. You learn that, rather than expending so much effort trying to elude the obstacles, you'll have much better success by throwing yourself toward them! If the obstacle is a rock and you lean into it you find increased stability. You can use the rock for support. If you allow yourself to get closer to the rock, you will notice a pillow of water recoiling off the rock that will assist you in moving around it. That pillow of water wasn't even detectable until you allowed yourself to get close to the rock. If you place yourself into a hydraulic on the river or a wave on the ocean, not just tentatively reach for it with your paddle, but throw yourself into it with your entire upper body, you will achieve increased and dramatic stability as you use the energy of the water to right and support yourself. As you begin to learn these things, paddling becomes much more dynamic and enjoyable. And you begin to connect with the river. Now you can begin to connect with the river and have more fun.
2. Do it Easily
The idea is to do it easy. If you are speaking, do it easily and smoothly using the fluency enhancing techniques we will discuss in a moment. If you are stuttering, learn to do it easier and smoother rather than struggling in the old, automatic and reflexive manner. Vary and play with the way you stutter, learn to monitor and selectively modify how you are using your speech production system. Take small steps.
3. Push the envelope
When you are ready, begin to accept speaking challenges that are just beyond your reach. I don't necessarily mean grand achievements. They can be seemingly small things like introducing yourself and saying feared words rather than avoiding them. Recognize that these are small but important victories and give yourself rewards for progress.
OTHER SUGGESTIONS
Changing the Surface Features
By features on the surface I mean the behaviors that we see and hear, the things people do when they stutter. By features under the surface, I'm referring to the fear, the loss of control, and the narrowing of choices based on the possibility of stuttering. The features under the surface are not often recognized or understood by the non-stuttering community and, unfortunately, by inexperienced clinicians. They do, however, represent much of the handicapping effect of stuttering. I'd like to first talk about changing the surface features.
1. Learn about the anatomy and physiology of speaking
Sometimes, as speech-language pathologists, we assume that everyone knows about the anatomy and physiology of the speaking mechanism. But, of course, most people don't. Some basic understanding of the components of this system are essential for making progress. This may be one reason we've found that, everything else being equal, medical students and physicians tend to make good progress in treatment. Their physical system is less of a mystery. They are better able to tune into what they are doing with their respiratory, phonatory, and articulatory systems. They are more likely to understand how to monitor what they are doing to make speaking so difficult and to see how to smooth out their breathing, voicing, and articulation.
2. Learn about the categories of speech sounds
It's also important to learn about the various basic categories of speech sounds such as the various types of vowels, glides, fricatives, and plosives. This also makes the act of speaking less of a mystery and helps you to monitor, and eventually, modify your speech.
Once you learn about your speech production system and about the characteristics of some sounds and syllables, you begin to get the feeling that your speaking and your stuttering is not something that is happening to you, but something that you have some ability to control. You can begin to systematically monitor tension and points of constriction in the vocal tract and to have some say about what you are doing with your system.
3. Learn some fluency enhancing techniques
As you have a better feel for your physical system and the nature of the movements that are necessary to produce fluent speech you can begin putting the two things together. The fluency enhancing activities that are often so successful with young children are also good for many adults. Even adults who do not stutter. Such targets as generating a full breath, establishing air flow, creating a gradual onset of phonation, producing light articulatory contacts, stretching and smoothing syllables, producing continuous phonation, and using slowed articulatory transitions are useful for all speakers. Of course, a lot of practice is necessary before these techniques can be relied upon in stressful speaking situations where there is a history of failure and penalty.
4. Learn some stuttering modification techniques
The same can be said of stuttering modification techniques. These are techniques that ask you to stay in the stuttering moment and gradually, with much practice in many situations, change the way you are stuttering. These wonderfully useful techniques usually go by the name of cancellations, pull-outs and preparatory sets. It's important to realize, however, that they must be overlearned if you want to rely on them in the stream of speech.
I'll give you one more analogy about kayaking that I think helps to illustrate the importance of overlearning techniques for use in a stressful environment.
A basic and essential technique of kayaking is learning how to roll yourself back to the surface after you make a mistake and find yourself upside down in the water. The great thing about it is that once you master the roll you have the opportunity to repair your mistakes. And if you are pushing the envelope with new rivers and new rapids you are likely to make a lot of mistakes.
As you might imagine, it takes hours of practice to master this technique. Again, some fear is involved because you are wedged into a small boat with a spray skirt stretched tightly around you. You're about to voluntarily go someplace where there isn't any air and you're not at all certain how long you're going to be there!
The roll isn't so difficult to learn in the safety of a pool with a good instructor nearby. You master the roll with and without the paddle and with the boat filled with water. But rolling when you have to in a real river is a different matter. After a time you realize that unless the techniques are not well learned, unless you can do them automatically in calm water, you cannot rely on them in the tumult of the river. If you've practiced the roll only to the point that you still have to think about what to do, what you will think about is how scared you are and you will panic. At the instant you realize that you're in trouble, you will bail out of your boat without even trying the first steps necessary for a successful roll. The technique has to be learned to the point that, when you unexpectedly find yourself upside down in the water, panic doesn't have a chance to enter the picture. Then you have the opportunity to get the real thing, your "river roll" or "combat roll".
As you begin to master the technique of rolling your boat you begin to let go of the fear. You are less concerned about making a mistake because you know that if you find yourself upside down you can cancel your error. You are no longer helpless in this situation because you can fix it. That's why learning to roll back up to the surface is such a liberating experience. You are able to regain control and give yourself another opportunity to paddle forward. Your body is more flexible and your are less influenced by the turbulence that pounds your boat. Eventually, with enough practice, you are able to monitor and modify your paddling techniques in order to anticipate and correct your loss of balance prior to finding yourself upside down.
5. Learn to produce good voluntary stuttering
After a lifetime of trying not to stutter it is a liberating experience when you finally give yourself permission to stutter. You can also give yourself permission to play with your stuttering. You can begin to vary how you do it and come up with better, easier ways to stutter. But first, you have to be comfortable enough with the stuttering to stay in the moment rather than reflexively running away. That, of course, takes real courage. When working with younger children I sometimes refer to this as swimming with the sharks as the Navy SEALS do during their training.
6. Be willing to Practice
Not much will change unless we practice. It will be necessary to practice every day. It is probably especially good to practice early in the morning to help set the tone for the rest of the day. We are faced with changing something that is difficult to change and something that is reasonably complex; something that is bound together with fear. Even less complex activities require much practice to become proficient.
Changing the Features Under the Surface
These features take longer to change. I suspect this is one reason why people who are fluent following a treatment program tend to relapse; the features under the surface haven't caught up with changes on the surface. There are a number of ways to change the cognitive aspects of stuttering- what you tell yourself about yourself and your stuttering.
Being associated with a support group is usually a great idea. If you've ever been in a support group of any kind you know how essential it is to understand, maybe for the first time, that you are not alone. The others in the group seem to somehow understand experiences and feelings that you thought only you knew about. There is strength in numbers and you begin to extend yourself and even take pride in your membership in the group. I don't think it is possible to underestimate the value of that kind of support both during and especially following treatment. It's a way of keeping stuttering from getting hot and it can be a way to advocate for others who share this experience with you.
One of the best new ways to connect with others who stutter and to learn about stuttering is through the internet. If you're not already aware of this resource the Stuttering Home Page by Judy Kuster at Mankato State University should help get you started (www.mnsu.edu/ dept/comdis/ kuster/stutter.html). To be sure, there are some silly things to be found on the net which are of no help at all. But there are wonderful resources, ways to learn, and to connect with others around the world.
Finally, the video tapes available from the Stuttering Foundation of America and The National Stuttering Association provide a great opportunity to understand the nature of stuttering and to watch good clinicians in action. They are no substitute for the actual process of treatment but you can learn a great deal.
HOW YOU KNOW THAT YOU ARE MAKING PROGRESS
As we have said, it's good to remember that change is cyclical, not linear. So sometimes it may not sound or feel like you are making progress when you really are. You may stutter more as you take part more. Because you now ask a question at work or in a class you have more opportunity to stutter. Because you now answer the phone or make a call, the frequency of stuttering may increase. Increased stuttering usually occurs with decreased avoidance. So, under certain circumstances, one sign of progress could very well be an increase in the frequency of your stuttering.
It's also an indicator of change when you begin to understand and appreciate the little victories. You recognize that, even though you stuttered, you were able to not let the stuttering run till the end but, rather, you were able to smooth out the sound just a little. You begin to feel more "good stuttering" in your speech. Or maybe you stutter as much as always but you walk away appreciating that you took part and did something that you used to avoid. One of our clients described a speaking situation by saying to us "You know, I stuttered as much as I always have but when I walked away from the person I wasn't embarrassed like I've been in the past." That is real progress and that is a wonderful victory! We need to recognize and reward that kind of change.
Another sign of progress is that you are being patient with yourself and that you are no longer chasing the fluency god. You are able to tolerate some fluency breaks in your speech and you are becoming desensitized to the sound and the feel of stuttering. This is an important early step for subsequent changes in the way you are speaking.
Good progress can be noted when others respond in a positive way to your fluency and your new roles. I don't necessarily mean responding by saying "My, you sound wonderful. You are so much more fluent than you were just a few months ago." Of course, that may be nice to hear. Or it may put a lot of pressure on you to keep being fluent. You think to yourself, "What happens if I lose it?". What happens if I start to stutter again?"
The kind of response I'm talking about is when people understand what's going on when you catch a moment of stuttering and change it into a smooth fluency break. They appreciate the fact that you are making a phone call or taking part in a meeting or generally putting yourself at risk doing something you would never have considered before. Or they recognize that you want to make your own phone calls or order exactly what you want in a restaurant. They are happy that you are more assertive and don't mind "shifting their position in the life boat" to accommodate your new role.
You begin to think of your stuttering less as a problem and more as a gift. Last year during a meeting in Antonio in 1998 my wife and I were sitting with a group of about 10 great people as we were having dinner. I thought about how much I enjoyed being with everyone. I said to them that had I never stuttered I would never have met a single one of them and would not be with them at this wonderful place tonight. Many of them stuttered also and we all agreed that being together was a perfect example of how our stuttering can truly be thought of as a gift.
If you didn't stutter how many of the people here today would you know? Do you think that you would be quite as sensitive and quite as understanding of the problems other people have if you had not suffered some? Would you appreciate the grand experience of speaking and enjoy the smooth flow of fluent speech that you do have had you not stuttered? Would you take speaking without getting stuck for granted as most people do? Of course, no one would choose stuttering as a characteristic or think of it as a gift at the outset. But, in fact, it can become one depending on how we interpret our situation.
Although there are other measures of progress I'll mention just one more. I think a great indicator of change is an appreciation of the humorous aspects of stuttering. At the outset of treatment few of our clients thinks there is anything funny about stuttering. However, when the people who have been in the group for awhile offer a number of truly humorous stories, the new people begin to understand. A humorous interpretation of the stuttering experience is only possible once the person has achieved some mastery of techniques and some distance from their stuttering. It also occurs as the person begins to make a conceptual shift about themselves and achieve a measure of control over the situation. There is a lot about stuttering that isn't funny. But I'll give you some examples that are.
A Conclusion
Whether you are in therapy with a professional clinician or whether you make the journey more or less by yourself, you are more likely to have success if you recognize what progress feels and sounds like. It's not an easy trek and often, it lasts a lifetime. But it sure is a lot more fun to do it with people of courage and with people who provide you with understanding, encouragement, and support. I hope you leave this convention with renewed enthusiasm for your friends - the people who are sitting around you this morning. Our journeys can become great adventures -- although it can be terribly difficult to tell that to yourself when you are lost, tired, feeling out of control, frustrated, angry or just simply being human in the face of adversity.
I'll leave you with one final suggestion; don't ever give up. Often persistence is the key for success with just about everything. Calvin Coolidge wrote something that I think may be helpful. He said: Nothing in this world can take the place of persistence Talent will not; nothing is more common than unsuccessful people with talent. Genius will not; unrewarded genius is almost a proverb. Education will not; the world is full of educated derelicts. Persistence and determination alone are omnipotent. The slogan "press on" has solved and always will solve the problems of the human race.
Thank you for inviting me to be with you today. I hope my ideas are helpful. And I hope you have some questions and comments.
August 6, 1999
