Assignments to Tackle the ABC's of Stuttering

About the presenter: Marybeth Allen, M.A., CCC-SLP, BRS-FD is a person who stutters, an SLP, and a member of the initial cadre of Board Recognized Fluency Specialists. She is on faculty of the University of Maine as a clinical educator and lecturer, and also works as a private practitioner, specializing in fluency disorders. Marybeth is on the Board of Directors of the National Stuttering Association and leads the Eastern Maine Chapter of the NSA.

Assignments to Tackle the ABCs of Stuttering

by Marybeth Allen
from Maine, USA

At first glance, transferring a newly learned behavior, such as using "pull-outs" or using "controlled fluency", to functional contexts through a series of hierarchical steps would seem to be what SLPs should be 'good at' ... it's "what we do" as part of being a therapist! But stuttering is multifactorial and complex disorder and very little about stuttering is "easy"! The term, ABCs of Stuttering (A=affective, B=behavioral, C=Cognitive) nicely sums up its complexity. Using this ABC model, at some point along the transfer hierarchy...whether it's making a phone call, ordering at McDonald's, or giving an answer in class... the stutterer's "old" negative Cognitions (thoughts and attitudes) about stuttering and/or about themselves as speakers and/or being capable "agents of change" creep into their picture frame. These cognitions precipitate an Affective response (fears, shame, guilt, ego threat) that will lead their body to produce Behaviors of physical tension and "fight or flight" responses Once that happens? - Those "shiny new" speech management Behaviors don't stand a chance! Yet, for those behaviors to become automatic and "easy to do" in these real life contexts, they must be practiced, and practiced, and practiced! And so the "ABCs" of stuttering produce yet another "vicious cycle": the new stuttering management and fluency behaviors don't "get practiced" and since they don't "get practiced", the behaviors rarely reach the level of automaticity needed for them to be able to be executed under more difficult contexts , such as "fear and tension".

It's important to address these ABCs throughout the therapy process as a way of moving the person who stutters forward, making steps towards change. There are many "clinician writers" that have written about ways to do this, and several of them are listed in the references below. The purpose of this paper is to describe the "ABC" assignment charts and logs that I use to guide my clients in a structured, systematic way during transfer assignments. I use these assignment charts at the point in therapy, where my clients and I already have discussed and created a situational speech hierarchy (i.e. parameters of situations in which my client predicts increasingly more frequent and more severe stuttering). In addition, we have already worked on and "found" my client's specific speech management tools they want to use. Depending on the individual needs and goals of my clients, this tool may be a single stuttering modification strategy (i.e. cancelling, pull out, and stuttering with reduced tension), it may be using a fluency tool (e.g. slowed rate, easy onset, and continuous phonation) or it may be the whole package of "controlled fluency". But whatever the new behavior, it is one chosen by the client and the goal is to begin to transfer it to actual speaking situations following their hierarchy.

The way it works is that we create assignment "charts" together in formats that include the ABCs. I act as a guide and direct the process so that the chart has a visual structure and contains a place to "process" the ABC aspects of that "homework task". I guide the process, yet at the same time, it's important that it becomes "their product". I guide the process to make sure that there are "slots" (e.g. a labeled column in a chart, a labeled rating scale) where the feelings (A), behavior (B) and thoughts (C) are identified and recorded. Attached to this paper are two examples taken from therapy records of two recent adult clients. In reality however, the real charts often "morph" as we use them, tweak them, and the client takes full ownership of them.

The attached, "Intentional Speech Practice", was developed with an adult client and worked in the following way: Using past therapy experiences and the hierarchy, she would decide on her/his weekly goal. For example, perhaps she's decides to make 2 phone calls each day and then use easy onsets as she says his/her name and then an easy onset at the beginning of next utterance into the phone. That's the "B" of the assignment, and we write it down in the 1st Goal column and draw an arrow down through the whole week. An important part of choosing this assignment would also involve a discussion of his/her hierarchy and where the "phone call" fits into it. We would also clarify the "who, what, where" of the phone call based on what she thinks the week will be like for her. We go over the rest of the "slots" on the chart and confirm she will be able to find time to record the outcomes of the task. Then, we'd have a discussion about the "feelings and thoughts" that are already coming to the surface about this assignment: How it will go? Do I think I am really going to do this?? That's the beginning of "A" and the "C" of the assignment. I don't always record this "predictive talk" on the charts, but consider it a "primer" in terms of helping my client begin processing this assignment. However, it's a good discussion to have because we might "practice" a new positive thought if I hear a negative thought crop up! Once the client returns to the next session, a large part of therapy is reviewing the 'outcome' components of the assignment. I expect the client's responses to be recorded on the assignment chart... Did it happen? Was she successful? Can she identify their thoughts surrounding the task? Did those thoughts change? How did you feel? Did you feel the same way before the phone call as afterwards? What would you do differently the next time? What are you going to think differently next time? From this discussion, the next assignment "out into the real world" is developed onto another plan sheet. Also, if the chart's "slots" didn't quite fit how she wanted to process and "debrief" the task, a new column /category/question could be added.

In the attached example, "Homework Plan", there are places for the same ABC content, but formatted a little differently according to another client's wishes. He liked the idea of making it like homework pages he used to have in "school"!

One very important thing I've learned over the years of using these structured ABC assignments and charts is that I need to be lenient and flexible. The charts will not always come back to therapy filled in! Life happens. It's okay to fill in the charts together if they come back partially completed, or if the thoughts and feelings are still "in my client's head". It's all about using them as a starting point to highlight and talk about the ABCs during the therapy session, not necessarily to be "graded if completed". The good work of "processing" the ABC's can still happens.

References:

Bennett, E.M. (2006) Working with People Who Stutter: A lifespan approach. Upper Saddle River, NJ: Pearson.

Bloom, C. & Cooperman, D.K. (1999). Synergistic Stuttering Therapy: A holistic approach. Boston: Butterworth Heinemann

Guitar, B. (2006) Stuttering: An integrated approach to its nature and treatment. Baltimore: Lippincott Williams & Wilkins

Finn, P. (2007), Self Control and the Treatment of Stuttering. In Conture, E. & Curlee, R. Stuttering and Related Disorders of Fluency. NY: Thieme. pp. 344-360.

Manning, W. H. (2010) Clinical Decision Making in Fluency Disorders. (3rd ed.) Clifton Park, NY: Delmar Centage Learning.

Manning, W. (2006). Therapeutic change and the Nature of Our Evidence: Improving Our Ability to Help. In Bernstein Ratner, & Tetnowski, J. (Eds.), Current Issues in Stuttering Research and Practice. Mahwah, NJ: Lawrence Earlbaum Assoc., pp., 125-158.