Clinical and Cultural Immersion: Internationalizing Stuttering Intervention

	About the presenter: David A. Shapiro, Ph.D., CCC-SLP, ASHA Fellow, Board Recognized Fluency Specialist, is the Robert Lee Madison Distinguished Professor of Communication Sciences and Disorders at Western Carolina University (Cullowhee, North Carolina, USA). In his fourth decade of providing clinical services for people who stutter and their families, Dr. Shapiro is a regular presenter at conferences and has taught workshops, provided clinical service, and conducted research in six continents. His book, Stuttering Intervention: A Collaborative Journey to Fluency Freedom, is in its 2nd edition (2011, PRO-ED) and continues to find a wide international audience. Dr. Shapiro is actively involved in the International Fluency Association (IFA) and International Stuttering Association (ISA), received IFA's 2006 Award of Distinction for Outstanding Clinician in Dublin, Ireland, and was elected IFA President in 2012. He is a person who stutters, has two young adult children with his wife, Kay, and lives near the Great Smoky Mountains National Park.
	About the presenter: Gregory A. Linge graduated in 2011 from Western Carolina University (Cullowhee, North Carolina, USA) with a Master's Degree in Communication Sciences and Disorders. During his studies at WCU, he was a participant in the clinical and cultural immersion program described in this paper. He is currently employed and completing his Clinical Fellowship in Alamosa, Colorado, working with a focus on assessment and treatment of people with neurogenic communication disorders.
	About the presenter: Eva Přikrylová is the Psychologist and Project Manager of Association LOGO (NGO), a prototypically inclusive clinical facility serving people of all ages with communication disorders. Mgr. Přikrylová hosted and coordinated Dr. Shapiro's four visits since 2004 to the Czech Republic, the most recent with five graduate students from Western Carolina University.
	About the presenter: Ilona Kejklíčková, Ph.D., Logoped/Speech-Language Pathologist, is the owner of Clinic LOGO, an inclusive clinical facility which serves people with communication disorders by utilizing a complex approach to diagnostics and therapy. In 2010, Dr. Kejklíčková celebrated the 20th anniversary of Clinic LOGO and invited Dr. Shapiro and his graduate students from Western Carolina University to experience the festivities. Dr. Kejklíčková lectures internationally about communication disorders and has made presentations at universities and conferences in the Czech Republic, Germany, Italy, Denmark, the Netherlands, and the United States. She publishes in newspapers and magazines and gives interviews on radio and television. Dr. Kejklíčková's book is titled, Speech Therapy in Nursing Practice. She is a member of ASHA.

Clinical and Cultural Immersion: Internationalizing Stuttering Intervention

by David A. Shapiro and Gregory A. Linge, USA, and Eva Přikrylová and Ilona Kejklíčková, Czech Republic

"There are other perspectives." This was the discovery of five graduate students in Communication Sciences and Disorders from Western Carolina University (WCU, in the USA) who collaborated with speech-language pathologists at LOGO, a private clinic in the Czech Republic. In this paper, we describe a graduate elective course (International Perspectives on Communication Sciences and Disorders) and preliminary outcomes that resulted from internationalizing stuttering intervention through clinical and cultural immersion as a form of professional education.

"The world has become a global classroom" (Shapiro et al., 2004, p. 125). This statement summarizes the conclusion of 17 clinicians and co-authors from 15 countries across 6 continents who engaged in a multinational investigation of stuttering intervention that addressed theoretical assumptions, clinical practices, and ultimate lessons. Furthermore, there is ample research attesting to the importance of professionals across disciplines being prepared for a changing world (Foster, 2009; Hanson, 2010; Shapiro, 2011). The American Speech-Language-Hearing Association (ASHA) recognizes the importance of globalization and collaboration of professionals in Speech-Language Pathology and Audiology in its Mutual Recognition Agreement among six countries (Tice & Moore, 2009). ASHA (2009a, 2009b, 2009c) also emphasizes the importance of exposure to and competence with diverse client populations and service providers within a rapidly expanding international community.

Guiding Questions and Objectives
Two questions guided the design and implementation of the graduate elective course and the international collaboration between WCU and LOGO:

What are the benefits of clinical and cultural immersion as a part of professional preparation in speech-language pathology?
How do personal, professional, and cultural demographics interact in the delivery of speech-language pathology services in diverse, international settings?

The course and the international collaboration were intended to provide a framework for conceptualizing, approaching, and interpreting new experiences, thereby enabling the student clinicians to develop a broader understanding of:

The world as a diverse and interrelated community.
The relationship of the individual to society and its culture and institutions.
The personal/professional impact of cultural immersion.
Historical, political, and cultural aspects of a community that is different from one's own.
Speech-language pathology practices in diverse, international settings.
The importance of clear and effective communication across disciplines and cultural settings.

The major purposes, therefore, were:

To experience the universality of communication, communication disorders, and clinical service.
To learn from excellent speech-language professionals who may not share our theories and assumptions.
To acknowledge that perspectives in the USA are not necessarily universal.

Procedures
During fall 2010, five WCU graduate students enrolled in International Perspectives on Communication Sciences and Disorders taught by David Shapiro (Syllabus). After reading and discussing papers about cultural humility and international service learning, the graduate students studied various topics related to the Czech Republic (culture, history, politics, literature, arts, language, cuisine, music, demographics, customs, etc.). They read Madam Secretary (Albright, 2003) and The Good Soldier Švejk (Hašek, 1993). They met several people with Czech background and experiences.

The preparation led up to a 4-day visit to Prague and a 7-day visit to Brno, the main site of LOGO, an inclusive clinic for people of all ages with communication disorders. Under one roof, professionals across allied health and educational disciplines (e.g., speech-language pathologists, audiologists, physicians, nurses, social workers, psychologists, regular and special educators, chefs, and more) collaborate on assorted traditional and non-traditional therapies (speech-language pathology and audiology, electro stimulation, physiotherapy, occupational and vocational therapy, EEG and biofeedback, stroboscopy and minor surgeries; dance, drama, music, art, aqua, massage, aroma, relaxation, cosmetic therapy, etc.). Dr. Shapiro had worked at LOGO with people who stutter, their families, and clinicians during three previous visits.

The focus of the trip was to engage in activities related to 13th Annual International Stuttering Awareness Day and the 20th anniversary of LOGO since the Velvet Revolution. The graduate students:

Attended a conference in Brno and made a presentation to clinicians from throughout Eastern Europe; the presentation was translated simultaneously from English to Czech, Slovak, and Italian.
Participated with Czech clinicians in the delivery of treatment and in self-help meetings of people who stutter in both Prague and Brno.
Became familiar with the organization and operation of one of the most inclusive clinical facilities in the world.
Toured clinical facilities and cultural landmarks in and around Prague and Brno.
Engaged in local celebrations and interacted with politicians and professionals from the Czech Republic, Slovakia, Italy and England.
Stayed in the homes of Czech clinicians.
Maintained a professional and personal journal.

Also during the trip, Dr. Shapiro delivered the keynote address at the conference, presented two clinical workshops, coordinated self-help meetings, initiated research with Czech clinicians, and participated in an interview published in Psychology Today in Czech.

Outcomes
The graduate elective course and the international collaboration between WCU and LOGO revealed a variety of positive and observable outcomes. Longer term changes are logically expected; shorter term changes included:

Perspective shifts -- Students applied alternative interpretations to their own professional and personal experiences. They began to realize that every event invites multiple interpretations and that their own individual interpretations are not necessarily shared. In fact, they discovered that the distinction between an event and its multiple interpretations is a hallmark of science.
Changes in ABC (Affect, Behavior, and Cognition) -- Students identified changes in their feelings, behaviors, and thoughts (i.e., see the students' reflections below).
"Pay it forward" -- Students shared new ideas and insights with other students in classes across the curriculum.
Public speaking opportunities -- Students presented to interdisciplinary audiences across the university campus and at national and international conferences.
Networking -- Students interacted with new friends and colleagues from the Czech Republic, Slovakia, the United Kingdom, Italy, and other European countries.

U.S. Student Perspectives

Several of the graduate students had experienced international travel previously; one had never been out of the USA. However, exploring their profession internationally and making a professional presentation were first experiences for all of the students. Their initial social, cultural, and clinical observations and reactions serve as a window into their experience, both personally and professionally. The graduate students reported that in the Czech Republic, they discovered:

Unparalleled kindness and hospitality.
Long work hours and unmatched professional passion.
An integrated professional and personal network (i.e., frequent social interaction among colleagues outside of the workplace).
Cutting edge technology.
Reduced focus on traditional interpretations of evidence-based practice.
Blending of diverse therapies noted earlier according to the needs of individual clients and families.
Individual and group treatments for people who stutter, including play-based therapy for children and self-help groups for children and adults.
Monthly staff meetings among allied professionals to discuss individual cases.
Professional openness, curiosity, and focus on inclusion and collaboration.
Differences in professional requirements (academic/clinical preparation, curriculum sequence, standardization/accreditation).

They also discovered:

Social acceptance of smoking and social drinking.
Openness to visual portrayals of nudity (i.e., on billboards, magazines, and the like).
More head (froth) served on the beer (so the patron knows the beer is fresh).
A social focus around food and the culinary experience.
Joyful living with daily celebration.

The graduate students best express the positive impact that the course and the international collaboration had on them, both personally and professionally:

Amanda
"The people in Prague and Brno impacted my life significantly and surely will impact the way I interact with others professionally and personally for the rest of my life. As we expand our professional circle and our personal comfort zone in the global community, we encounter people who are worthy of modeling in actions and attitudes."

Gregory
"As a graduate student with guided academic and clinical experiences, witnessing diverse international and clinical perspectives and methods was inspirational and provided a broader context for conceptualizing the role of a clinician. What I saw -- clinicians treating people with multiple diagnoses and working on multiple goals simultaneously, coupled with interdisciplinary collaboration -- elevated intervention to a gold standard. The trip to the Czech Republic was the most awesome experience of my life."

Lindsay
"Observing diverse professionals under one roof brought inclusion to a whole new level. When people share a common interest, language barriers simply dissolve. I learned that our perspective is only one perspective, not the perspective. I also learned that when you approach an experience with an open heart and mind, life changes you."

Claire
"This was my first professional conference that addressed stuttering therapy using art, music, and drama. The speakers' ideas inspired me to 'think outside the box' and reflect about my career and the type of clinician I want to be. I learned that no one idea, technique, or frame of mind prevails over another. I learned that the world is not so big and commonalities can be found no matter what type of barriers exist."

Kate
"Our adventure was a life-changing experience. I learned many new treatment techniques for children and adults from speech-language therapists in the Czech Republic and the United Kingdom. Opening our minds to differing points of view does not mean we necessarily agree with the perspective but acknowledges that we can learn from the thoughts and ideas of others. Despite our differences, we are all working for a common goal: to help, to learn, and to better the lives of people with communication disorders."

Czech Perspectives

Likewise, the positive impact was reciprocated by our Czech hosts:

Jan Tomšej, Co-Owner of LOGO
"It was an honor for us to welcome professionals from all over the world. Exchanging knowledge of diagnosis and therapy of speech disorders and working with whole families improves the care of people with disabilities. We learned about patients from abroad and different approaches in treatment of communication disorders."

Ilona Kejklíčková, Co-Owner of LOGO & Speech Therapist
"We are very pleased that Prof. Shapiro and his students visited the Czech Republic. They got to know our methods for treating communication disorders at LOGO. We are proud to collaborate with Prof. Shapiro and look forward to continued cooperation."

Radka Florianová, Speech Therapist
"Meeting American students with Prof. Shapiro was a great occasion to learn about speech therapy from abroad. We discussed the similarities and differences in services and professional preparation in our countries."

Jakub Ostrý, Speech Therapist
"The visit of American students and Prof. Shapiro provided for exchange of information about speech therapy in different countries. This extraordinary occasion revealed international interest in LOGO and our professional methods."

Eva Přikrylová, Project Manager & Psychologist
"We are very proud of our longtime cooperation and friendship with Prof. Shapiro and are happy that he visited with his students. We enjoyed showing our work, our facility, and our strategies."

Summary and Conclusions
Avenues are available for internationalizing professional education of speech-language pathologists. Indeed there is benefit for understanding stuttering and stuttering intervention through clinical and cultural immersion. This preliminary experience revealed positive, observable outcomes in five student clinicians' thoughts, feelings, and behaviors, creating an expansion of influence both on and by others, from local to global. Furthermore, the international hosts expressed the positive influence of interacting with clinicians from the USA, which created opportunities for receiving and sharing new ideas and insights. Plans are underway for a visit of the Czech clinicians to Western Carolina University. Clearly, global education must influence clinicians' skill sets as we prepare to serve a rapidly changing world. People with communication disorders and their families deserve no less.

PHOTO ALBUM

References

Albright, M. (2003). Madam Secretary: A Memoir. New York: Miramax Books.

American Speech-Language-Hearing Association. (2009a). Standards and implementation procedures for the Certificate of Clinical Competence in Speech--Language Pathology [2005 Standards for the CCC]. Available from www.asha.org/policy.

American Speech-Language-Hearing Association. (2009b). Standards for accreditation of graduate education programs in audiology and speech--language pathology [Chapter 3 in the 2009 Council for Academic Accreditation Manual]. Available from www.asha.org/policy.

American Speech-Language-Hearing Association. (2009c). Strategic pathway to excellence [ASHA's Strategic Plan]. Available from www.asha.org/policy.

Foster, J. (2009). Cultural humility and the importance of long-term relationships in international partnerships. Journal of Obstetric, Gynecologic, & Neonatal Nursing, 38(1), 100-107.

Hanson, L. (2010). Global citizenship, global health, and the internationalization of curriculum: A study of transformative potential. Journal of Studies in International Education, 14(1), 70-88.

Haŝek, J. (1993). The good soldier Ŝvejk. New York: Everyman's Library/Alfred A. Knoph.

Shapiro, D. A. (2011). Stuttering intervention: A collaborative journey to fluency freedom (2nd ed.). Austin, TX: Pro-Ed.

Shapiro, D. A., Abbink, M., Bortz, M., Bruna, A. V., Cook, F., Dhu, P., et al. (2004). A multinational investigation of stuttering intervention: Assumptions, practices, and lessons. In A. Packman, A. Meltzer, & H. F. M. Peters (Eds.), Theory, research and therapy in fluency disorders: Proceedings of the Fourth World Congress on Fluency Disorders (pp. 123--138). Nijmegen, The Netherlands: Nijmegen University Press.

Tice, P, & Moore, M. (2009, January 20). Six nations now participate in certification recognition. The ASHA Leader, pp. 34--35.

SUBMITTED: August 2, 2012

Return to the opening page of the conference