Results Are the Problem with Stuttering Therapy

People who stutter can become fluent speakers. However, this will never happen by trying to speak fluently.

This might seem like just one more of the many paradoxes related to stuttering, but it is actually common sense. That is, it is common sense if you are talking about playing tennis, dancing, skateboarding, writing, cooking, constructing a chair, or even a sand castle. In all these activities people understand that there is a way to carry out these activities effectively. They know that results depend upon the process that goes into doing them. When results are not as they want them to be, the natural tendency is to think, “Hmmm… What do I need to do differently?” i.e. feel the music, hold my body differently, add more flavors, cut the wood straighter, etc.

For some reason stuttering doesn’t cause people who stutter and those who would like to help them think with that same kind of logic. Perhaps this is part of human nature because it has been going on for centuries. People seem to want to change speech fluency without considering the process of speaking. They want the speech to be smooth by trying to make the speech smooth. They want to get words out fluently, even though words are not a thing to get out, even if you want to get them out gently. They wonder why a person who stutters can speak fluently when alone, but not in front of a crowd. However, they don’t come to grips with how thoughts directly affect speech production, and they don’t focus on how to change both.

The belief that stuttering is a thing, not the result of a process, is so firmly and indelibly planted in peoples’ minds, that it is hard to accept that stuttering doesn’t come and go. It is not a thing that happens to you. It is a challenge for people to accept that stuttering is the brain using an ineffective network for the activity of producing speech. We know from the latest research that people who stutter use a different brain process for producing speech, but in treating stuttering this fact is so often ignored. People still think that you can change stuttering by changing the speech, i.e. speaking rate, number of pauses, levels of tension, etc. The result is frustration, because these techniques only occasionally and only inadvertently cause changes where changes need to be made – in brain processing.

I know many people will not agree with me when I say that people who stutter can become fluent speakers. This is because these people are focused on results (fluency and stuttering). I have seen again and again that people who stutter can change the way their brain functions to produce speech. It takes time, repetition, changing thoughts and awareness. It is not a quick and easy change, but people who stutter can do it, and when they do, naturally fluent speech is the natural outcome.

The greatest breakthrough for people who stutter comes when they say, “Hmmm.. I blocked on my name today. What was I doing that I can change? What were my thoughts and how can I change them?”

Spotlight on Stuttering: Don’t miss Barbara and her client, Ariel, in a TV interview

Stuttering Online Therapy and Communication Therapy Institute Director Barbara Dahm will be featured in a televised interview in New York and North New Jersey. It will air at 6 PM, 7:30 and 11 PM on Thursday, January 27. In New York, as well as North Jersey, it will also air on 13/WNET at 6 PM, as well as on NJN. Please let Ariel know, too.

UPDATED: You can now watch the interview online here.

Therapy Appointments Available in January-February in Midland Park, NJ

I am pleased to announce that from January 24 – February 24, 2011, I will be available for in clinic consultations and treatment at Ridgewood Speech and Language Center, Midland Park, NJ. This is an opportunity for those of you in the area who prefer the more traditional framework to receive treatment. While I am in NJ, I will also be treating younger children for whom online therapy is not appropriate. Any necessary follow-up to the one-month treatment program can continue with the staff of RSLC and through me online.

Of course, during this time I will continue working with my clients online. In fact, this is a good opportunity for those of you in the USA who want online therapy during the evening hours to schedule sessions at your most convenient time.

For an appointment, please contact me at

barbdahm@gmail.com

or call

Ridgewood Speech and Language Center

317 Godwin Avenue

Midland Park, NJ 07432

Phone: 201-444-6305

Whose Fault Is It? Part Three

Several weeks ago I started a 3 part series in which I talked about whose fault it is that so many people who stutter are disappointed and dissatisfied with their treatment experiences. In part 1, I discussed that the approaches for treating stuttering need to be revised. In part 2, I talked about the inability of professionals to change the paradigms that they were taught and trained to believe are the best that can be. Today I am focusing on the people who are being treated, the people who stutter.

First I want to say that I strongly believe that everyone who comes to therapy wants to “get rid of the stuttering”. Furthermore, I think that most clients put their trust in their clinician and are willing to work hard to become fluent speakers. To some extent, while they are doing their absolute best to do what the clinician asks of them, it is this trust that is part of the problem. I believe that there are some clients who need to take a more proactive role in the therapy process. When they are asked to use a technique, they need to question how it is meant to help. Also, if they have honestly tried to do what was asked of them and found it to effortful or difficult to do, they have the responsibility to say that the technique is not working for them and, together with the clinician, explore where the problem lies.

Speech is one of the neurophysiologic systems of the human body that is meant to work automatically. It should not be an effort to speak. If it is an effort, something is wrong. Clients should not accept directives and goals that add layers of cumbersome controls. Clients who come to therapy without questioning what is being asked of them are at fault when they don’t get what they want.

It is very understandable that clients need to be encouraged to investigate the logic behind what they are being asked to do. This is why Dynamic Stuttering Therapy explains the process of normal speech production and is so centered on self exploration. I don’t want clients to do something because I say so; I want them to do what makes sense to them. Some clients do begin therapy thinking that I can make them fluent without their help. They do not want to be bothered with the details. Explanations and discussions are of little interest. During the initial intake it is normal to want to know results of therapy. However, during therapy clients who continue to believe that change comes by osmosis do not make the change that is necessary for a successful therapy experience.

Clients who expect that therapy is a quick fix cause their own disappointment. Therapy is a process of self-change. To be honest, speaking naturally is not a difficult process to learn. However, learning the process is only part of what therapy entails. I sometimes see clients who after 3-4 hours of treatment begin speaking with a degree of ease and fluency that is unfamiliar to them, even during their more fluent moments. In their joy, they expect to go off into their lives and their speech will remain fluent. This expectation is unrealistic. Developing a normal speech production system requires developing or at least strengthening the specific neurological network that results in fluent speech. This can only be done, with intention, mindfulness and repetitive experience.

I have discussed the three factors that are at fault for the failure of therapy to bring the understandably desired results. At the same time, I have touched on how these three factors can improve the situation. The poor outcomes that are traditionally associated with stuttering therapy need not be allowed to perpetuate. Open minds on the part of clinicians and clients will enable more people who stutter experience effective treatment and the ability to speak with ease and fluency.

New Year Wishes

During this special time of year, I want to wish all of you who are celebrating Christmas a very Happy Holiday. I hope Christmas will be a meaningful day for you and that you will have the opportunity to celebrate with family and friends.

While you are celebrating, I want to wish you the opportunity to speak freely and to resist the all too natural tendency that people who stutter have to avoid speaking. We all know that effort to avoid stuttering increases the frequency and severity of stuttering. For this reason it is far better to speak without concern of whether or not you will be able to say this word or that one.

Giving up trying to avoid stuttering is not easy.  However, a good 1st step toward doing this is to start talking more openly about the subject of stuttering. This helps, because once the subject is out in the open, the fear of having your stuttered speech heard is somewhat reduced.

This Christmas holiday as you are sitting around the table or visiting with friends and relatives, it will be easier than ever to bring up the subject of stuttering. All you have to do is mention having seen, or not having seen yet the new movie, “The King’s Speech”.  For anyone who has not yet heard about or seen this movie, it focuses on the effect of stuttering on the life of King George VI of England and his speech therapy.  What a wonderful icebreaker for the subject of stuttering!

As the New Year approaches, this is also be a good time for new beginnings, for looking at stuttering in a new way, for making 2011 the year that you make the changes that make it easier for you to speak. During the coming year I am planning to continue sharing my thoughts about stuttering, my knowledge about how to treat stuttering effectively and some of the experiences of my clients as they actually make these changes.

I wish you all a very Happy New Year!

Pros and Cons – part six in a seven-part series

A look at Stuttering Therapy Online – a seven-part series

Please join us next week on Wednesday as we examine the unique aspects of treating stuttering with online therapy.

This week’s focus – pros and cons of teletherapy

From my point of view, there are many benefits in online treatment, including flexibility in scheduling, the ability to present my perspective to people all over the world, and the client’s ease in contacting for short consultations between sessions if they are experiencing difficulty with their self-help assignments. I am really hard pressed to think of the detriments. However, it is more important to consider what clients feel. The following is a summary of clients’ perceptions.

Pros:

  • Extremely convenient
  • Practicing in a familiar place feels relaxed and makes it much easier to make changes
  • Comfortable for people who work
  • Since the practice is done in the comfort of the person’s home, he can then continue practicing even without the clinician and there is no psychological  ”barrier” due to the change in location. For me it was easier to continue practicing and using the correct process even when you (the clinician) weren’t there because it was in a familiar place. That was really important at the beginning of the therapy.

Cons:

  • There are no cons I can think of. At first I thought that since you can’t actually see me in person face to face you won’t know if I’m using the right process or not, but this was clearly not the case. I think that the reason why it was successful for me is because you were able to identify when I was using or not using the process.

Last week: Participation Procedures

Coming next week: What Clients Say About Teletherapy vs. Regular Therapy

Participation procedures – part five of a seven-part series

A look at Stuttering Therapy Online – a seven-part series

Please join us every Wednesday for the next two weeks as we examine the unique aspects of treating stuttering with online therapy.

This week’s focus – participation procedures for teletherapy

The procedure for participating in online therapy is quite simple. People contact me through my website or email. Once they send me their skype name we set up an appointment for a free initial consultation. During this meeting we begin to get to know each other and can assess if online therapy is the right option for the individual. We also have an opportunity to sort out problems with the connection, cameras, microphones, headsets or even lighting conditions. If, after this consultation, the individual decides to begin treatment, we set a time for the first session.

Sessions are from 45 minutes to 1-½ hours depending on the stage of therapy and other personal criteria. All sessions are held by appointment only. Being prompt and available at the agreed time is a requirement. Since I am treating people in various time zones, I try to be as flexible as possible with my treatment schedule. Often the time zone differences work to everyone’s benefit, because I can keep fairly normal working hours while the client can participate in therapy either very early in the morning before going to work or during the quiet hours of the evening.

There is no magic number of sessions required. I have divided the treatment process into these four stages. Stage 1 focuses on understanding speech production, and doing activities to change the way you speak and relate to yourself as speaker. In Stage 2 the client gains heightened awareness of speech processes and does repetitive exercises in normal connected speech while creating new thoughts. During Stage 3, the client etches the process in procedural memory while gradually increasing use of new process at will in real life. In Stage 4 the client uses the new way of producing speech automatically in real life as part of the subconscious self.

Roughly speaking, Stage 1 & 2 take 3-6 sessions each, depending on the individual. Stage 3 takes from six months to a year of mainly self-practice and gradually incorporating changes into real-life situations. Sessions with the clinician in Stage 3 are optional and depend on the client’s feelings and personal need for support.

Clients do not have to commit to a certain number of sessions. Ideally, it is best to have clinical guidance at frequent intervals during stages 1 & 2, but progress can be made at a slower rate with less frequent sessions. Payment is made per session via PayPal. Some people have a very small budget for treatment so they suffice with only minimal direction and continue on their own. Others work through one stage with me, take a break while reinforcing what they have learned, then return for a few more sessions to work through the next stage. Still others prefer to have me guide them through treatment until they are well into stage 4.

Units of the Dynamic Stuttering Therapy workbook are sent to clients for their personal use as they progress through therapy. All people who participate in treatment work at giving up unnatural control of the speech production system and developing the normal automatic way of speaking. However, the content of the sessions are individualized to suit each client’s needs.

Last week: Appropriate Populations

Coming next week: Pros and Cons of Teletherapy

Appropriate populations – part four of a seven-part series

A look at Stuttering Therapy Online – a seven-part series

Please join us every Wednesday for the next three weeks as we examine the unique aspects of treating stuttering with online therapy.

This week’s focus – the appropriate population for teletherapy

At Stuttering Online Therapy, I treat people who stutter from approximately 14 years through adult. When treating children under age 18, I require an online consultation with parents or legal guardians before beginning therapy and at intervals during the therapy process. Parents are invited to sit in the room with their child to learn the treatment principles. This allows them to offer support and assistance between sessions and throughout the self-help phase of therapy.

People who participate in therapy must have a working knowledge of English or Hebrew. Some clients have a different native language. Therefore, some of the basic exercises are practiced in languages that I do not understand. This does not present a problem because achievement of the Dynamic Stuttering Therapy goals is not language dependent. I can identify speech processing in any language. Later in treatment clients often speak in their native language with family or friends who sit in on sessions.

Last week: Technical Requirements

Coming next week: Participation Procedures

Technical requirements – part three in a seven-part series

A look at Stuttering Therapy Online – a seven-part series

Please join us every Wednesday for the next five weeks as we examine the unique aspects of treating stuttering with online therapy.

This week’s focus – technical requirements for teletherapy

The technology available for videoconferencing is constantly improving. The treatment platform must be reliable and easy to use. It is very important for the client and me to be able to see and hear each other clearly. The video streaming has to be natural and the lip and audio sync have to be good. Delays in either audio or video would make it difficult for me to evaluate what the client is doing and make it impossible to model differences in speech processing that are important to the treatment goals. Another requirement is file sharing. I send clients units of the Dynamic Stuttering Therapy Workbook and rely on diagrams, pictures and videos to clarify explanations. I also need to video and audio record clients with an option for immediate playback.

I tried out a handful of companies that are Mac compatible and offered white board and file sharing along with video streaming capabilities, but was disappointed with the quality of video streaming, the audio, or the synchronization of the two together. Also, I found that many platforms were difficult for new users to learn. As a last resort I tried Skype, the commonly used instant messaging platform that many people have or that can be easily downloaded at no cost. It works beautifully. The video and audio quality is usually good and has improved over the past two years. Incidentally, I have also used ichat/AIM, but have not been as happy with the video quality. Skype has options for sending files and screen sharing. It does not have a recording option, but I solved my recoding issues by purchasing both an audio recorder http://www.rogueamoeba.com/audiohijack/ and a video recorder http://ecamm.com/mac/callrecorder/. Together, I have all the recording functionality that I have in clinic.

Clients can record their practice between session on their personal MP3 or on computer recording software. For those who don’t have this software, a free personal recorder can be downloaded from Audacity http://audacity.sourceforge.net/ .

While most times the connection quality is good, there are interferences that need to be considered. Occasionally, the video freezes or the voice cuts out. Most of the time this can be resolved simply by hanging up and reconnecting. On occasion it is necessary to reboot the whole system. The video/audio quality can be greatly improved by using a decent web cam and headset with microphone. Each of these can be purchased for under $100 in most countries. I always use a headset with an attached microphone during treatment. However, some of my clients do not use one. The necessity depends on the quality of the built in hardware.

Last week: Ethical Considerations

Coming next week: Appropriate Populations for online therapy

Ethical considerations – part two in a seven-part series

Please join us every Wednesday for the next seven weeks as we examine the unique aspects of treating stuttering with online therapy.

This week’s focus – ethical considerations of providing therapy online

Telepractice must comply with the standards of in person therapy. Initial comparison of videoconferencing and conventional face-to-face speech language therapy has indicated that children made similar progress with both methods, and students and parents overwhelmingly supported the telemedicine service delivery model (Grogan et. al., 2010). I have not formally studied differences in treatment results, but my experience supports these findings.

Online assessment requires special consideration, because some assessment instruments are copyrighted and cannot be transferred to clients online without permission. For subjective assessment, I rely on information from the initial interview and the Speech Satisfaction Scales that are part of the Dynamic Stuttering Therapy protocol (Dahm, 2007). Assessing fluency, speech rate and length of blocks, can be easily done online by recording speech samples. That allows for quick assessment using the SSI-3 (Riley, 1994).

Care needs to be taken to ensure the client’s comfort, privacy and confidentiality. My clients electronically sign a statement agreeing to the terms of treatment and giving permission to record speech samples for training purposes. I am careful not share identifying information or recordings without explicit permission. Speech samples are saved in files on an external hard drive. Skype sessions are held in a private place and no one is allowed to observe sessions without the client’s permission.

When treating people in countries foreign to the provider, it is important to be sensitive to cultural, linguistic, religious and geopolitical issues so as not to cause discomfort to clients. I feel honored to be able to treat people who stutter who I would otherwise not have the opportunity to know. Sensitivity and respect for differences is imperative. This extends to topics for practicing conversational speech, modesty in dress, and other cultural differences. Having lived both in the Middle East and the United States, I have learned a lot about differing cultures. This understanding, and the bond we share of wanting the experience to be successful has a positive impact on service delivery.

Last week: Series Introduction

Coming next week: Technical Requirements for online therapy