Intentional, Theory-Based Counseling in Stuttering Therapy
About the presenter: Gunars K. Neiders, B.Sc., M.Sc., Ph.D. (Electrical Engineering) and M.A. (Counseling Psychology), is employed as a systems engineer/computer programmer at the Boeing Company. He is also a registered counselor in the State of Washington. His special interest has been programming real time systems as well as Artificial Intelligence and Decision-Making Algorithms. In school he had a minor in mathematical logic and has had a life long interest in both philosophy and the philosophy of science. He is a member of the American Speech-Language-Hearing Association as a "Member without Certification" and is a member of SID4, the Special Interest Group on Fluency and Fluency Disorders. He is a long time member of NSP, where in the seventies he was the local leader of the Seattle Chapter. His main interest is the application of brief cognitive therapy to the stuttering therapy process.
Intentional, Theory-Based Counseling in Stuttering Therapy
by Gunars Neiders
from Washington, USA
Introduction
For a long time the author has been concerned about the status of counseling in the field of stuttering therapy. The author understood that to do a credible job, he had better survey the field, use his newfound information to assess the status of counseling in stuttering therapy, and then proceed to make some suggestions.
Before starting on this endeavor (the survey, the analysis, and the recommendations to the stuttering therapy professionals) it was necessary to clarify what is meant by counseling. Taber’s Cyclopedic Medical Dictionary (Thomas, 1997) gives the following definition, "Counseling — The providing of advice and guidance to a patient by a health professional." While the dictionary's definition is short and to the point, it is this writer's opinion that much more is involved in counseling. Counseling, in its broadest sense, includes guidance in clarifying values, setting goals, fulfilling societal roles, adjusting to one’s situation in life, overcoming internal and external obstacles to leading a full life, performing daily tasks, building skills, dealing with personal conflicts, changing self-defeating beliefs, and changing unhealthy negative feelings.
When the definition of guidance is expanded as above, the term psychological counseling becomes more appropriate since to obtain any permanent change in the clients' cognition, affect, and behavior, other elements must be added such as Socratic questioning, assigning of psychological, action-oriented homework, and requesting reports of outcome behavior together with the observed affect and self-talk (the cognitive element). Counseling then may even include verbal and non-verbal experiential exercises and catharsis (letting the person blow off steam).
The picture is further befuddled by the realization that Sheehan (1958), Froeschels (1957), and Van Riper (1954) might well be right when they considered stuttering therapy to be a specialized form of psychotherapy. Assuming that this is so, all of the action-oriented assignments both in the clinic and outside of it are part of the general process of psychotherapy or psychological counseling. Since the current stuttering literature does not reflect this definition, the author will use the term counseling to deal with the non-behavioral parts of the problem, that is, the cognition and affect. Thus, for example, when the main goal is to talk the client into doing voluntary stuttering or pursue a specific target in fluency shaping this will be called stuttering therapy. When, on the other hand, his beliefs, self-talk, or his feelings before, during and after doing an assignment are discussed, this will be considered a counseling event.
The term intentional counseling is used to distinguish this type of counseling from the spontaneous and unguided counseling that occurs in any setting where advice is given. Theory-based counseling is counseling which is based on some theory, such as gestalt therapy or rational emotive behavior therapy. Included in theory-based counseling is integrative counseling, which is counseling based on more than one theory or technique.
Survey of Counseling in Current Stuttering Therapy
Method of Survey
With the above definitions in mind, the author proceeded to survey the field of stuttering therapy as follows. He acquired and read fifteen recent books of stuttering theory/therapy (Bloom & Cooperman, 1999; Bloodstein, 1995; Schwartz, 1999; Conture, 1990; Manning, 1996; Cordes & Ingham, 1998; Culatta & Goldberg, 1995; Curlee & Siegel, 1997; Guitar, 1998; Starkweather & Givens-Ackerman, 1997; Shapiro, 1999; Ratner & Healey, 1999; Webster & Poulos, 1989; Breitenfeldt & Lorenz, 1989; Goldberg, 1981). He also reread portions of twelve of his "golden oldies" (Van Riper, 1973, 1971, & 1963; Johnson, W., 1961; Gregory, H.H., 1968; Hegde, 1985; Eisenson, 1958; Sheehan, 1970; Barbara, 1962; Pellman, 1947; Rieber, 1966; Bloodstein, 1987) which yielded some interesting observations to be discussed later.
General Findings
The results of the survey are arranged in chronological order with the most recent publication first. The writer has done his best to convey the various authors' attitudes toward intentional, theory-based counseling. If the writer has missed the mark, he welcomes any corrections to his impressions:
Bloom and Cooperman’s (1999) book is best described quoting from the back cover of their book. "Learn the details of a synergistic stuttering treatment program that integrates the principles of speech production with the socioemotional aspects of communication. The authors guide you through the synergistic process that includes the interaction of speech-language, attitudinal, and environmental components. Discover how to structure individual treatment plans based on your client's attitudes, behaviors, and interactions within their environment. The importance of counseling and how it can be incorporated into therapy is emphasized throughout." [italics added]...[This book] "provides a variety of counseling procedures." In the summary of the chapter on counseling, they write, "In this chapter, we highlighted the necessity of speech-language pathologists recognizing the importance of incorporating aspects of counseling into therapy. As clinician-counselors, we must be knowledgeable about the helping process. In addition to examining the phases of the helping process, we defined and expanded on the dimensions (the Counseling Triangle): (1) the personal development of the clinician-counselor, (2) the theories of counseling from which we draw on understanding of both counseling issues and counseling techniques (we examined four theories - psychoanalytical, person-centered, gestalt, and rational-emotive therapy), and (3) the skills of counseling."
Shapiro (1999) appears to favor the humanistic approach to counseling in stuttering therapy where the "the dialogue between the clinician and client is the medium of exchange." Shapiro is both humanistic and client-centered in his approach to counseling. He stresses the training of the clinician and preparation of the clinician to have the proper thoughts, feelings and beliefs, so as to be more helpful in the "collaborative journey to fluency freedom."
H. D. Schwartz (1999) has a chapter on "Counseling persons who stutter". Basically he provides a unified counseling view based on the works of Vaillant (1977), Ellis (1977), and Dryden (1987). He discusses both appropriate and inappropriate topics for counseling. Having clearly delineated when expert help is to be called in, he proceeds to teach the basic counseling skills. He clearly specifies his goals of changing the feelings via disputing the irrational or self-defeating ideas, as well as guiding the client through rough spots in therapy. Describing his stuttering therapy, Schwartz (1999) states, "Upon initial inspection, our program may be viewed as a fluency shaping program …[however,] we place a great deal of emphasis on the client’s emotions and emotional reactions associated with stuttering."
Murphy’s (1999) contribution is a chapter in Ratner & Healey's book, Stuttering research and practice: Bridging the gap. He establishes the need for counseling due to shame and guilt, but does not provide any discussion of counseling methods. (The omission of discussion of counseling techniques is probably due to the scope of the book.)
Guitar (1998, 1997) discusses feelings and attitudes and even goes as far as stating "The reason [that advanced stutterers will not be able to modify their stuttering successfully] is that, like most people, stutterers cannot adequately control fine motor acts, such as modifying a moment of stuttering when they are wrought up emotionally." Yet counseling is not explicitly discussed in the book. While discussing stuttering modification he explains the Van Riper belief that most stutterers "have developed strong feelings of frustration, fear and shame focused around their disorder." He restates Van Riper’s belief that these emotions can be reduced via "(a) discussing stuttering openly, (b) deliberately using feared words and entering feared situations, (c) freezing or holding on to moments of stuttering and (c) using voluntary stuttering."
Starkweather and Givens-Ackerman (1997) base their counseling on Gestalt therapy and the 12 step-programs. "The three stages of recovery — awareness, acceptance, and change — are not a one two three formula for therapy. They are performed over and over again for different behaviors, thoughts, and feelings as they occur. …The …clinician’s role in this recurring cycle is that of conversationalist. A conversation is a way to develop an idea through the use of language. Therapy takes place in the domain of language…Therapy is essentially a creative process, whether it is seen as an art form, a scientific endeavor, or some combination of both." Starkweather (1999) further clarifies his stand when he concludes, "By joining the client in a recovery process, rather than trying to change him or her, it may be that we can be more effective."
Manning (1996) presents a whole chapter devoted to "Counseling strategies and techniques" where he establishes the necessity of counseling and describes the various alternatives. He presents an integrative approach, which includes a survey of counseling psychology, and then proceeds to show how the various techniques can be incorporated in stuttering therapy. He builds on the works of Egan (1990), Luterman (1991) and Ellis (1977). He presents the view that counseling should be an integral part of stuttering therapy. Manning stresses the importance of relationship in the counseling process. The therapeutic …"relationship is also likely to be more crucial than the treatment strategies or techniques." He continues, describing Egan’s (1990) thinking, "… we clinicians must understand the limitations of our profession, the shortcomings of the treatment strategies and techniques, and the strengths and weaknesses of both the clients and ourselves. We must recognize that the dogma of treatment approaches and book learning can filter and on occasion bias what we would otherwise understand about the person we are trying to help." Quoting Manning’s (1996) own conclusions, "Many things are good for people. Exercise is one of them, having a network of good friends is another, and there is no question that counseling is beneficial for humans, especially those of us who have specific problems. This is true for communication disorders in general and fluency disorders in particular."
Culata and Goldberg (1995) establish the need for counseling with adults, but do not provide any guidance except to say, "Approaches may be as direct as rational-emotive therapy…, as introspective as Jungian therapy…or as non directive as client oriented therapy…" They also warn the stuttering therapist not to go beyond her expertise in counseling, but to let the psychological problems be handled by the experts in that field. It is interesting to note that Goldberg (1981) models the counseling techniques that he uses via small dialogues. Most of his examples deal with trying to teach the client to accept the responsibility both for his fluency and disfluency.
In discussing the effectiveness of treatment Bloodstein (1995) states, "Treatment must remove not only stuttering, but also the fears, the anticipations, and the person's self-concept as a stutterer". In his conclusions he states, "It is that the ultimate basis for essentially all true recovery from stuttering is to be found in the observation that if stutterers could forget that they were stutterers, and in so doing forget to do all of the things that stutterers think they have to do in order to talk, they would have no further difficulty with their speech." He later continues, "It is possible to summarize these inferences [from documented cases of recovery] adequately by saying that the basic therapeutic problem posed by stuttering may represent the kind and degree of difficulty involved in rooting out a superstition, dogma, or prejudice [in the stutterer's own mind]." This writer looked for a recommendation of some heavy duty counseling, but instead found the following inconsistency: Bloodstein (1987) writes…"some believe that psychotherapy [gestalt, rational emotive therapy, and most other varieties of psychotherapy] may be a useful or necessary adjunct to other methods of treatment in many cases". However, in his last edition of The handbook of stuttering (Bloodstein, 1995) deletes that part of the sentence.
Conture (1990) in brief passing mentions the counseling of parents, but for adult stutterers there seems to be no intentional counseling, except for imparting information and keeping group discussions going. He admonishes "When there is too much group discussion about attitudes, beliefs, and feelings about speech, some clients seem to lose interest and feel that the group is becoming too esoteric, non substantive, and of minimal relevance to their specific problems." Yet in various instances he gives advice, such as how to motivate the client, which is tantamount to intentional counseling. "Make your praise emphatic, be demonstrative in your praise (but not ridiculously so), and use positive emotional tones in your speech, "That was a good change, Tom." " Here he has followed his advice to emphasize the event [act] rather than the personality. That is, he eschews using such phrases as, "You have become a good talker."
W. G. Webster and M. Poulos’ (1989) manual, Facilitating fluency: Transfer strategies for adult stuttering treatment programs is almost entirely devoted to counseling and self-talk, an approach that is omnipresent in most of the cognitive behavioral therapies. This book was first developed for use with the Precision Fluency Shaping Program but can be applied as well to stuttering modification. This is a step by step manual of cognitive behavioral counseling, based on rational emotive behavior therapy, and can be used by the stuttering therapist in almost a cookbook fashion. Later, as the therapist matures, the material in the book can be tailored to the temperament and needs of both the therapist and client. "Through a series of five seminars, backed by readings and reproducible worksheets, this program will show your clients how to: [a] change their attitudes and beliefs by changing their self-talk, [b] attack avoided words and situations, [c] do progressive relaxation exercises to control physical tension, [d] use diaries to monitor their speech performance and plan speech activities, and [e] develop "scripts" to enhance their social skills.
Van Riper (1973, 1971, 1963, 1958, 1954) had a lot to say about psychology and stuttering therapy. In 1954, he outright considered stuttering therapy as a specialized form of psychotherapy. His desensitization techniques were borrowed from the field of psychology. In his 1973 book he devoted a whole chapter to "psychotherapies, drugs, and group therapies." Although he describes various therapies, such as client-centered, rational emotive therapy (now evolved into rational emotive behavioral therapy), gestalt therapy, analysis, reality therapy, and group therapy, he stops short of recommending any of them, except in special cases.
Sheehan (1970) wrote, "Most of what we call speech therapy for stutterers is, in reality, a role-taking psychotherapy. The logical models are those of role theory, learning theory, and behavior modification therapy." However, the problem is that nowhere in Sheehan’s writing is there a discussion of the counseling aspect of psychology - be it cognitive behavioral counseling, or any other type. Moreover, he states, "You are changed by what you do. Not by what you think about, read about, or talk about, but by what you actually do."
Rieber (1966) writes "Sheehan (1958) and Van Riper (1954) …conceive of speech therapy as a specialized form of psychotherapy. Sheehan (1958) points out that the most efficient therapist in the treatment of stuttering would be a therapist who has had thorough training in speech pathology as well as psychotherapy." Rieber agrees with Sheehan and goes on to point out that "If we are to help the secondary stutterer in the fullest sense, it appears to this author that a direct symptomatic approach must be well integrated with both the supportive and reconstructive aspects of psychotherapy. For instance, in the reconstructive aspects of therapy the stutterer should be helped to recognize his personal feelings, attitudes and values, as well as gain insight into how they developed and how they influence his present behavior."
Villarreal (1962) states "…that stuttering is the kind of problem that is inadequately treated by either specialty [stuttering therapy and psychotherapy] without the active aid and assistance of the other." Having defined that "defect would stand for the vocal mechanism-centered aspects, and handicap would stand for the social situation-centered aspects", he suggests that "the therapist as a speech pathologist, treats the problem of stuttering as a speech defect; while the therapist as psychotherapist treats the problem of stuttering as a speech handicap." In the summary he states, "A significant dimension of stuttering, calling for therapeutic attention, is an area of emotional disturbance. Whether this emotional disturbance is viewed as the basic cause of stuttering or the inevitable result of it, makes little difference to the present argument. What is important is that it is there and needs attention." No specific type of psychotherapy was mentioned.
Pellman (1962) states "An adult stammerer usually has had a number of experiences with speech therapy and often seeks a speech therapist who will work with him along the lines that he has decided encompass the problem." He outlined a number of areas where counseling the client to think differently [the task of modern cognitive behavioral therapy] would help the client to recover. Pellman (1947) predates the cognitive psychology era but his advice comes right out of the best traditions in it. To wit, "As a stammerer, the child worries about people’s opinions of his disorder and frequently himself. [Let the reader note how clearly he states that the behavior is not the person.] This drives him [the child] to try to conceal it — futilely, of course. The parent must reason [sic] with the child and help him understand there is no need to be ashamed of stuttering."
Johnson’s Stuttering and what you can do about it (1961) falls in the other camp: He advocates semantically based counseling with no readily specified speech assignments. The book is written as an essay on General Semantics (Korzybski, 1941). There are no real structured counseling sessions identified, although the general gist is to focus on your normal speech and work at "being a normal speaker". (One of the exercises suggested is to build a fluency base by talking with oneself.) This writer was hard pressed to take away with him any strategies or techniques such as those employed in modern cognitive behavior psychotherapies which are also semantically based.
A number of authors Breitenfeldt and Lorenz (1989), Curlee and Siegel (1997), Hedge (1985), Gregory (1968) and Cordes and Ingham (1998) treat counseling and psychology as a taboo subject. It neither appears in the index nor is it easily apparent from reading the text that any intentional counseling, takes place or should take place in the stuttering therapy process.
Conclusions
During the literature search the author found some good examples of intentional, theory-based counseling (Bloom & Cooperman, 1999; Manning, 1996; Schwartz, 1999; Starkweather & Givens-Ackerman, 1997; Webster & Poulos, 1989; Shapiro, 1999). As might well be expected, there is no consensus upon which theory to base the counseling. The theories run the gamut from humanism (Shapiro, 1999), gestalt (Starkweather & Givens-Ackerman, 1997), 12-step (Starkweather & Givens-Ackerman, 1997), rational emotive behavior therapy (Schwartz, 1999; Webster & Poulos, 1989), and integrative therapy (Bloom & Cooperman, 1999; Manning, 1996). Bloom & Cooperman (1999) draw on four basic theories in counseling: (1) psychoanalytic therapy, (2) person-centered therapy, (3) gestalt therapy, and (4) rational emotive behavioral therapy (REBT). Manning (1996) has integrated REBT with Egan's (1990) and Luterman's (1991) approaches.
The writer would like to encourage practitioners to consider the following three points. Firstly, Crowe’s (1997) observation as reported in Bloom and Cooperman (1999), "Counseling, in fact, does occur in almost every therapy encounter, whether it is intentionally employed by clinicians to achieve specific therapy goals, or whether it happens spontaneously and unguided toward any purpose." Secondly, intentional, theory-based counseling makes more sense than spontaneous, unguided counseling. Lastly, much could be gained by elevating the topic of counseling in stuttering therapy to a bona fide subject for learning, teaching, and research.
For those who want to investigate available psychological techniques on their own, the best books to read are: a) the classic work by Harper (1959), b) the currently recognized authoritative work by Corsini and Wedding (1995), and c) a work on brief therapies by Bloom (1997). Harper (1959) reviewed thirty-six therapies and discussed his findings in very clear language. Unfortunately, Harper’s book is dated, and out of print. Corsini and Wedding's (1995) book is in the fifth edition attesting to its popularity and durability. In this book the various practitioners, often the founders, describe the most important psychotherapies today. Bloom's (1997) work, also a compendium of the practitioners, is especially geared toward the brief therapies, therapies which were designed to produce results in a few sessions.
Acknowledgements
I would like to thank Judy Kuster for limiting the body of the paper to three thousand words, my wife Regine for helping me to realize that I was trying to write six papers in one, Zanville Green, Esq. for editing the first draft, and Dr. Scott Yaruss for dropping a couple gentle hints how to make the paper better. Finally, my heartfelt thanks go to Dr. Larry Molt who reviewed the final draft and made many helpful suggestions.
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Footnote:
1 The manual can be ordered from:
The Institute for Stuttering Treatment & Research (ISTAR)
3rd Floor, 8220 -114 Street
Edmonton, Alberta
CANADA T6G 2P4
Phone: (403) 492-2619, FAX (403) 492-8457
September 23, 1999
