Stuttering Treatment Strategies for Affective and Behavioral Roadblocks

[Music] hello my name is Lourdes Ramos Heinrich's and I work in the Boston Public Schools and I didn't work in a mid past on public school for 16 years a long time and before the Boston Public Schools I was working in the San Diego School District for six years and I developed a special interest in stuttering about 16 years ago which is the time when I received my stuttering specialization and it has been a wonderful experience having this special session because I've been able to really make a difference in the life of so many people

who stutters and their families and the teachers I help them to understand better ways to communicate with students who stutter and how to help them out and also I am a stuttering consultant for my colleagues in the Boston Public Schools so in that job role what I do is I go around the school district when SLP is some call me and ask for my assistance in helping them to understand assessment how to assess a child who stutters or how to develop a steroid program that is effective and this this workshop is called parents treatment strategies

for effective and behavioral roadblocks and that is a big issue out there in the schools and people working with students who stutter is working with the behavioral components and the social-emotional components because many people many slps before they get experience working with stuttering the big focus that they have is on the fluency shaping so they start using certain strategies on fluency shaping and then they come to a point where it's frustrating for them and also for the students because it's difficult for the the client to bring the D fluencies to the natural environment so my

speaking to my speaker's disclosure is that I'm an employee of the Boston Public Schools as I said and I received the financial compensation from Asha for this presentation and my nan financial disclosure is that I have no man financial relationships to the content of this presentation many persons who stutter can easily achieve speech fluency targets within the clinical setting you can see many times when clients come and you model for them in the clinical setting easy relaxed speech and then suddenly they're doing it they speak very fluently and they start relaxing and and then you

begin to think oh wow the child is really making a lot of progress and then many times it gets to the point where were these therapist thinks oh this child is so fluent when I see no flute no disfluencies at all when they come to the clinic so they must be ready or the client must be ready for this missile or to be discharged but we have to be careful because many clients show poor carryover to the natural environment and often there are parents that come crying to the office saying my child is stuttering so

much and they don't want to come to school anymore they are struggling and the therapist gets into this conflict with the parents saying no your child is fluent i contradict and the parent and so that becomes a real conflict between the therapist and the parents that were the therapy to see influencing in the clinic but the parents and the teachers have mercy in the fluency this child is breaking down in the classroom and at home and so many clients relapse to prepare at the levels when we make a decision to discharge them because we don't

see the disfluency in the office or in the clinical setting so stuttering treatment can be a it can be complicated it gives against them to be complicated but really it's very manageable and any speech therapist has the skills to effectively treat a client who stutters and the components that we look at are not different from the components that you look at when you are assess ascertain any child or any person that is referred for an assessment for example you look at definition you look at the articulation are there any articulation problems often stuttering has some

people who stutter have articulation issues as well some may have language issues some may not or you may see some the research shows that there is a little bit of a delay in persons who stutter compared to the control population often the social pragmatics in in people who stutter is is a big issue that needs to be looked at such as how is the eye contact how is the the person's ability to initiate a conversation and the conversation maintain a topic of conversation listened to to the two other people the transition from one topic to

another so that's all social pragmatics that need to be looked at a lot of people who started to make of issues with auditory feedback so that's something that also needs to be assessed and looked at and make a determination is that is an issue for this particular client that you have feelings and emotions is a very important component that many times when I go to the schools to do consulting with other therapists I often hear a therapist saying or the client says that he doesn't care that he stutters or that he feels okay with it

so and then I ask the you do you have any data the you do you do any assessment and they say oh I didn't think about doing an assessment so I talk to them about doing the administering B for example the cat communicative assessment tools and and so from tools like this you get a lot of information that is subjective and you get numbers and you get data that helps you to understand the client them to understand what kind of issues they are facing with their emotions and their perception about themselves and their stuttering difficulty

for example do they have a perception that other people view them or evaluate them in a negative way because of the stuttering so we don't know that and the client is has difficulties revealing that information or verbalizing that information so we need to help them communicate that information to us by administering our tools in questionnaires that can help them to explain those concepts that can be very difficult for them to do as to the clinician so we also look at perception you know how does it person who stutters how do they view themselves as communicators

which is very important in the treatment of stuttering the perception their communication in stuttering as I imagine in any other speech communication disorder there can be a negative cycle that can be developed for example the person might think okay I'm having difficulty communicating I get stuck I cannot say what I want to say and it's embarrassing people laugh I people are going to think I'm incompetent and then that begins to develop into self-doubt and distrust like oh I wasn't able to say my name or I wasn't able to tell my teacher that that I needed

to go to the bathroom so so that becomes into shame and worry because all the other kids are witnessing that difficulty and then that begins to have more difficulty into the speech mechanism which this speech mechanism is sensitive to feelings and emotions so then that begins the cycle again so it is important to address cognitive and emotional struggles in stuttering treatment and so there is one approach in to deal with social emotional and behavioral components there are many approaches in in this field that that help us the speech therapist to target those areas of therapy

for example cognitive behavioral therapy is some is an approach is a behavioral therapy approach that tell us that problems emerge through conditioning from the environment and from other stimuli for example when a person who stutters they are receiving negative conditioning from their own speech and from the reaction of there's of others in in Denver in their environment they see mom getting embarrassed mom getting uncomfortable with their speech others speaking for them so that's the negative conditioning that is coming from the environment when we try to do therapy for this clients after a while of many

experiences of negative reinforcement then it becomes very difficult for the client to control the negative feelings and behaviors through rational thought so so then the therapist we have the the job of helping the client to re-establish their positive self-esteem in their confidence of themselves and so we have approaches in our field that helped us in a systematic way to help the client to change I suppose I shall fall stinking to a more realistic frame of mind for example and hopeful thinking could be I'm not going to the to the party or to the birthday party

because I'm going to stutter and that's going to be embarrassing and the other kids are going to laugh and they're going to think I'm incompetent so that's an example of a thoughtful thinking so in the approaches that we use as therapists we are going to help the client to develop a more realistic frame of mind in cognitive behavioral therapy and stirring is a it's a very good way to start for many slps and a lot of times we feel uncomfortable dealing with counseling and often often people slps express the basis that they're not trained as

counselors and so they feel uncomfortable dealing and helping the clients with social and emotional reactions to the stuttering but we're going to see in this presentation that we are well equipped as stitch therapists to address the needs of the clients the social-emotional needs so that they can be so that they can become better communicators more comfortable with themselves so the the concept in cognitive behavioral therapy is that condition fears originate from the stimulus in avoidance responses so the avoidance response could be I'm not going to the birthday party so that's an avoidance or I'm not

going to tell I'm not going to speak to the principal or I'm not going to order at the restaurant so that's an avoidance response and so over time this responses this avoidances become conditioned into fears so becomes difficult to change and so in our therapy we want to change the maladaptive thinking so that we can have a more positive effect and behavior so cognitive behavioral therapy is effective in reducing the social anxiety in in adults that's what it research has shown and and I can tell you from my personal experience in children you see a

positive change in their social anxiety related to speaking in a matter of one or two sessions the kids are happy and they say oh I didn't know that is okay to feel uncomfortable that it's okay to feel nervous or to feel embarrassed but I'm going to choose to communicate and to develop my communication skills one thing that has to be pointed out is that committee behavioral therapy is hasn't been tested so much for reducing stuttering frequency as though as though often you might see reductions in stuttering frequency when the child is able to relax the

child or the person who stutters is able to relax and feel more comfortable and more accepting of themselves and their disability so in cognitive behavioral therapy the objective is to decrease the cognitive distortion and to increase the mindful thinking so mindful thinking would be for example saying to yourself I I am part of this community I'm part of this classroom what I have to say is important and it's going to be helpful to to the other people I'm a member of this community so so I'm going to go to the cafeteria with everybody I'm going

to be accepting my the fact that I have a disability in that sometimes I'm going to have difficulty speaking but it's not going to be impacting my ability to integrate myself into my daily life into my community my friends my social setting my family contributing my ideas contributing the important things that I have to say so in community behavioral therapy the client gains control of his mind by focusing the attention to the present moment breathing is important often the person forgets to breathe because they are thinking so much they're so nervous about you know that

they're going to stutter or that they're going to get stuck on the T or the C or you know some sound so they're so worried about that they for to breathe and so they so so we need to teach them right in therapy with really the about realistic thoughts about human communication human human human communication we have a lot of errors and we have a lot of opportunities to to communicate and say what we want to say and to be accepted as we are and to be accepting of other people with the difficulties that they

might be having in in different areas so we want to be able to replace the discursive thinking the discursive thinking being you know all these thoughts that you might be having you know I'm going to fail as a communicator people are going to laugh and so you the person begins to go into that world internal world and they forget about the present moment you know you know who is here this is my my little brother I wonder what if he has an issue whatever to see when I tell me or this is my little friend

I wonder how good weekend was I wonder if she enjoys herself at the field trip so you know we want to bring the client outside of their mind and into the real world what is the communication with all the imperfections that there are in it so one tool that we can use as some speech therapists to help the clients to communicate to us what issues they are facing in their daily life is that the clinical use of the report and the SSI four has a very good tool which is called the clinical use of self-report

and this tool is used to systematically collect data at regular intervals to assess the emotional and the cognitive reaction and to provide helpful clinical information for managing a dynamic treatment plan in and often very often if you ask a client who stutters how is it going a lot of times they might say all is going ok going ok so a tool like the clinical use of service self reports is going to help the client to say yeah I'm having issues when I'm talking to a thirty figures and then there's a scale from zero to ten

right now today I was nine I was having a lot of difficulty communicating I was having a lot of repetition I was having secondary behaviors when I was trying to talk to my mother or to a teacher or someone in authority so but without this tool the client that might not be able to communicate they might just say oh it's going okay how is it going it's going okay so we don't have a way we are the Destroyers given a de client a system a way to be able to express what they are experiencing in

the real world and so in this tool for example in the clinical use of circuit port the client communicates that perceived stuttering severely how severe mi when I'm talking to my friends maybe I'm very fluent when talking to my friends what about when talking to more challenging audiences like maybe a the police officer or the secretary in the in the office or when given a presentation in the class how am I like maybe maybe you are very fluent in one setting and very disfluent in another setting so this tool is helping the client to communicate

in what settings are the more challenging and also this tool is helping the client to express the extent of the internal and external locus of control how much do they feel that they have control of their speech is it like something that is just happening the disfluency is just happening and they have no control what is making it happen or is it the the site of an authority figure or the site of the principal or the site of the parent that is determining the level of fluency or is it internal do I need to control

my body and it relaxed I need to breathe I need to focus on whether on what I'm saying and on the communication so that's the level you know how much control is appala is some is that is coming from the client versus the control that is coming from outside forces so the avoidance is to the client that naturally is not going to tell you all you know I was having difficulty ordering in a restaurant but when you get when you give them the the questionnaire the self-report they can tell you specific information that can be

very helpful in the clinical setting and in addressing the specific needs that the client has and I'm talking about the the clinical use of the report but there are many the one I'm in the exercise for is a very helpful one and it's very thorough and it explains each one of the items the areas that are being targeted and so for example in the clinical use of self reports in the SSI for each item in the scale assists the client in communicating to the clinician their feelings their fears their avoidances and other emotional struggles related

to the stuttering and the impact on daily interactions for example this is this is one page in the clinical use of self report any demonstrated data that was collected is over three sessions so they were session I'm session 2 and session 3 and the most effective area we can see in the data is communicating with strangers and authority figures and the least affected area is communicating with family members in close friends so when we look at this data we might want to look at what is the client doing when communicating with the family members maybe

they are more relaxed maybe they're breathing better maybe they are more open to listening to what they are saying so so we need to look at what strategies the client is using that makes them to feel more relaxed with family members and then we can carry those skills or those strategies and apply them to the to the most affected areas such as communicating with strangers and authority figures so many of the skills that we need to use for communicating are very similar you know taking relaxing listening to others having eye contact responding to question and

questions asking questions for similar very similar skills that can be transferred from a more comfortable setting and more in easier audiences to more difficult and more challenging audiences so in this day that you can see that over three sessions there is a marked decline in each one of the areas being measured and as we can see with the authority figure this particular client was having the most difficulty communicating and they in he was this client was trailing himself there is high indicating that he was having the most difficulty communicating with the authority figures so in

addition to finding out what the client is doing what skills they are using to communicate with easier audiences also the therapist can obtain resources from books or stuttering programs for example the styrene foundation has great resources that can help the therapists to help the client to express and communicate feelings and emotions with challenging audiences so you can obtain resources from the steroid foundation and also if the Google you can google how to talk to or thirty figures and there is min much there is a lot of information in the internet that you can look at

and see if it's applicable to your particular client so in one approach that is used and that is gaining popularity to deal and to help clients to understand and to deal with their difficult social emotional components of stuttering is the solution focus brief therapy in the solution focused brief therapy is um there is a video that the stuttering Foundation of America has with Francis Cook and we live but really from England and they explain in great detail and they try to coach the therapists that are viewing the video on becoming more competent in using this

solution focus brief approach to help the client to feel more comfortable among themselves and to develop their own solutions and their own coping mechanisms to their situation the solution focused therapy approach has five key questions that you address in therapy so I have a very good handout that is called the solution focus brief therapy and in this handout I explained in detail the history behind this approach and I give a lot of examples for each one of the components for each one of the five components on what kind of questions to ask so that you

can help the clients to start developing their own solution to their own problems and so these are in this some solution-focused bruschetta P handout you can practice you can take some of the questions if they're applicable but those are example questions that you can use to help you develop your own questions in your own therapy so the for example the miracle there are five questions five quick key questions one is the medical question this scaling question exception seeking questions quoting questions and problem free talk so for example this data that I have here is based

on a real client and I was applying the solution focus brief therapy approach and so in the miracle question I asked what might be the small change that you might see when you feel that you are being more fluent and then he answered I would naturalist type the chest would be relaxed when talking so right here you can see that this is important to the client is not to feel as tight on the chest area so this is data that you can take and you said to help the client to achieve that particular goal and

the scaling question is for example from zero being no confidence to 10 being having the best confidence how would you rate your position when talking to strangers and so this this client said on a bad day is 3 why because they will give me weird looks my confidence is lowest when I'm tired and him sleep but I would aim to attend so again here the client is giving you a lot of very important information that you can use in helping them to achieve their goals this third question is exceptional seeking questions and in this to

my I asked my client can you explain why the problem is less severe or absent at times and his answer was I work on being more calm think of others breathe so again here you are given you're getting information from the client as to what is it that they feel that they need to do and that they are ready to start working on so this particular client of mine was ready to learn strategies to come to become more calm and more relaxed and to think of others so so to stop thinking about their own struggle

and communication and think about others you know which is also another key point another key concept a key skill that you can take to help the client how how do you help clients to think of others and in the field of stations speech and language therapy we have the pragmatic approach social language we have a lot of resources that can help us in this area in helping clients to communicate more effectively with other saying how to breathe you know that's part of what we know as therapists we know how to do that really well and

so we can help our clients how to breathe and how to relate that to our speech so we can we can have better speech with better breathing and then the fourth question is coping question how do you manage to participate in life and the answer is is all about my goals I'm ambitious and I don't want to be held back by this stutter so here again is giving you ideas that the client is ready and motivated and excited to participate in life so this is very important for you to effectively be able to help the

client to make those the incentives transition to achieve the goals that they want for themselves so in summary effective treatment in therapy is multifactorial and is based on the needs identified during evaluation cycles they're important to continually evaluate and provide the the questionnaires to the client to show to communicate what they are feeling what they are experiencing as another handout that I have for you is some something that is like the clinical use of surf reports but I generated this one that to make it easier to use in the clinical setting at the beginning and

you can use this as an option or you may use the one from the exercise 4 which is the one that I presented here in this talk the handout that I presented score I call the feeling emotion self-assessment report for stuttering so again I have a lot of different questions that the client can can answer to communicate to you or a lot of different statements about 22 statements that the clients can use to help you communicate what they are experiencing in the in their life so that you are able to help them with those particular

issues that are very personal to them also is really important to remember that beliefs thoughts and cognitive distortions have to occur at the outcome and that's a very important part of the speech therapy with persons who stutter is to address to find out what they what they believe about communication by other thoughts in their cognition and their feelings their affective components of stuttering in address those in the cognitive and emotional struggles must be addressed in therapy for in order for the client to be satisfied and to have positive results from therapy is very important not

to matter neglect the cognitive and the emotional struggles and so in this in my handouts I'm giving you two tools which is the solution focused brief therapy Chris handout and also the feelings emotional self assessment report which you can use to help you understand what the client needs at this particular moment in time clinical self reports help communicate feelings fears avoidances and other behavioral struggles to the therapist as we said before the clients who stuttered even adults have a very difficult time verbalizing what is it that is bothering them or why is that there is

having avoidances or why are they feeling so so many fears in communicating or why do they perceive negative reaction so that they are feeling negative being that they are being negatively evaluated by others so all of these are behavioral struggles that are communicated to the therapist so that you can help the client and so the solution focus brief therapy approach is one approach that can help the client to envision a better future