Bilingual Self-Report for Persons Who Stutter (BSR) / Auto-Reporte de la Tartamudez Bilingüe (Lourdes Ramos-Heinrichs, Sandra Garzon)

lourdesAbout the authors: Lourdes Ramos-Heinrichs, MA, CCC-SLP, BCS-F. Lourdes works full time in the Boston Public Schools as a Spanish-English bilingual speech-language therapist. She is a Board Certified Specialist in Fluency Disorders.  Throughout her career, she has published and presented nationally and internationally on topics related to fluency and fluency disorders.  In 2014, She chaired an ASHA Coordinating Committee Project Team on Reading Fluency and co-authored various presentations and papers based on this research project. She regularly mentors SLPs who wish to obtain their specialty recognition in fluency disorders. Lourdes coaches and mentors her fellow SLPs in the Boston Public Schools and in local universities, counseling them on best practices on clinically servicing children who stutter. In her role as fluency mentor in the Boston public schools, she has opportunities to observe children who stutter across the school district, facilitate best assessment/therapy outcomes, and influence administrative decisions that impact children who stutter. She is looking forward to a future partnership with stuttering organizations in Mexico, her country of origin.
sandraAbout the authors: Sandra Garzon, MA, CCC-SLP, BCS-F. Sandra is a bilingual speech-language pathologist and a Board Certified Specialist in Fluency Disorders.  She has worked in the Boston Public Schools for the last 25 years and specializes in dual language learners in the preschool and school age populations. Sandra is a member of the American Speech and Hearing Association (ASHA), Division 4 (Fluency and Fluency Disorders), Division 11 (Administration and Supervision), and is also a member of International Fluency Disorders Association (IFA). She is trained in Parent Child Interaction (PCI) at the Michael Palin Center in London and Solution Focused Brief Therapy (SFBT) at Boston University.  Sandra counsels and treats parents and families of at-risk preschool children from culturally and linguistically diverse backgrounds. She continues to deepen her understanding of bilingual stuttering treatment. Sandra enjoys traveling with her family particularly to her native Colombia.

The BSR is a clinical tool that promotes pride, respect and dignity among persons who stutter in treatment.  The scale enables the client to communicate cognitive and emotional reactions to the stuttering, as these can be elusive and difficult to verbalize.   Being able to identify, rate, and express struggles with communication empowers the client; even small positive changes in how life is approached can be recognized and celebrated.  The idea is to support the client in developing self-awareness, compassion, and kindness toward the self.  Rather than professing to know all the answers, clinicians promote self-discovery by recognizing that solutions to problems lie within.  Professionals need to validate the stuttering experience by providing a means for the client to talk about it openly, document it, rate the severity on a scale, and systematically reflect on it during therapy sessions.  Through the self-report process, clients connect with their own stuttering experience and take an active role in making the journey of healing a dignified one.

Bilingual Self-Report for Persons Who Stutter (BSR)

Auto-Reporte de la Tartamudez Bilingüe

The BSR is a bilingual, English/Spanish, Likert scale that allows SLPs to informally measure changes in their clients’ emotional and cognitive reactions to stuttering.  The scale is written both in English and Spanish to allow Spanish-speaking clients to participate in the self-report process.  The BSR can be reviewed with the client at each session to ensure that updated information is driving therapy programming.  Client responses to the questionnaire can help the therapist to understand if treatment is producing desired outcomes in terms of carryover from the clinical setting to the natural environment; and any reported positive changes from session to session serve to motivate the client to continue or intensify efforts to reach fluency goals. If a client reports no changes or notes a decrease in fluent behaviors such as increased social avoidances, the SLP can promptly reprioritize treatment goals.  Thus, the client’s reported changes, or lack thereof, in this questionnaire can be used to guide direction or pace of treatment, and to guide relevant topics of clinical conversation from session to session.

There are a few scales on the market that aim to elicit detailed information from persons who stutter about their own views, perceptions and feelings about their personal experience of stuttering (Clinical Use of Self-Reports in SSI-4, 2009; Camperdown Program, 2016).  The BSR elicits responses from the client that can be looked at quickly to inform the SLP of emotional/cognitive struggles that need immediate attention and the BSR can be paired with other treatment programs to allow the therapist a glimpse of how the client is responding to treatment.  For more detailed analysis of emotional and cognitive struggles, the OASES can be used to perform an extensive overall assessment of the speaker’s experience of stuttering (Yaruss and Quesal, 2006).

The BSR is a three-page scale that assists in data collection for understanding the client’s current communication needs and emotional/cognitive responses to stuttering moments. Due to the complexities of the stuttering experience, the client may struggle to unpack thoughts, feelings and emotions that may be causing roadblocks in the recovery of fluent speech (e.g., “I worry excessively about how I say things”).  It is not uncommon for SLPs to follow generic therapy programs that are purchased commercially.  Although extensive research and thought have been invested in the creation of commercially available programs, the therapist must remain flexible in the application of such programs and be ready to revise treatment goals based on information provided by the use of self-reports.

The use of self-report effectively assists clients to communicate their speech difficulties and fluency concerns in precise language.   Random communication exchanges in the clinical setting can result in frustration and poor client-clinician relationship.  To exemplify an ineffective clinical scenario, the following dialogue looks at a verbal interaction that may occur between a clinician and a client: the clinician asks, “So how is it going?”, and client responds, “It’s going good.”.  This dialogue may be followed by the therapist saying: “Good job!”, and then, without further exploration of responses to treatment, transitioning into fluency targets such as slow-speech or other verbal skill that may be useful to achieve fluency within the clinic but results in poor carry-over into the natural environment.  In this mock clinical dialogue, the opportunity to gain powerful information from the client that can be used as raw material to optimize best clinical outcome is lost through the unstructured exchange.

The SLP can promote, through systematically collected data, the practice of self-reflection on how beliefs, attitudes and feelings affect progress towards desired outcomes.  In our own clinical practice, BSR information has been used to guide the client in the development of a constructive view of the self as a dignified person with great talents and a unique personality. We believe the most valuable outcome of any stuttering treatment program is the emergence of self-acceptance, confidence, and self-advocacy.  It has been a fulfilling experience to see our own clients become more confident as they take ownership of their own recovery.  Initially they may be surprised to learn that fluent speech occupies only a small piece of the treatment program, but soon they realize the value of cultivating positive attitudes and warm feelings toward oneself.  In our experience, many clients initially need a lot of encouragement to increase tolerance and acceptance about their stuttered speech; and it helps to expose them, early in the treatment, to famous people who stutter that have overcome their speech challenges and have gone on to achieve at a high level (e.g., Vice President Joe Biden).

The BSR Likert scale reveals the intensity of each emotional/cognitive reaction that impacts the client’s ability to communicate.  It prompts the client to report on the following aspects of the stuttering-experience: (a) perception of the speech difficulty, (b) efforts/avoidances, and (c) beliefs/attitudes and feelings about the communicative concern.

Data collected from the BSR allows the SLP and client to improve communication about communicative struggles, feelings and avoidances.   Information from the self-report helps the SLP to make informed clinical decisions and to be better able to shape desired behaviors through validation of even small changes in therapy outcomes.  The client should be empowered to take ownership of his/her own stuttering experience.

The BSR helps to de-emphasize stutter-free speech as the ultimate goal in stuttering treatment.  The aim of stuttering therapy is for clients to regain positive perceptions about their speech, to effectively manage their feelings, attitudes, and beliefs and to reduce social avoidances. Persistent thoughts, feelings of unworthiness, and punitive internal monologue (e.g., “I’m incompetent.”) adversely impact recovery from stuttering. A positive indicator of success in therapy manifests when the client expresses a sense of freedom from emotional struggles, demonstrates relief from shame, and begins to participate fully in life.

References

Camperdown Program. (2016) Australian Stuttering Research Center. http://sydney.edu.au/health-sciences/asrc/clinic/adolescents/camperdown.shtml

SSI-4: Stuttering Severity Instrument – Fourth Edition. (2009)  Pro-ed.  An International Publisher.

Yaruss, J. S. and Quesal, R. W. (2006) Overall Assessment of the Speaker’s Experience of Stuttering (OASES): Documenting Multiple Outcomes in Stuttering Treatment. Journal of Fluency Disorders, 31, 90-115.

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Bilingual Self-Report for Persons Who Stutter (BSR) / Auto-Reporte de la Tartamudez Bilingüe (Lourdes Ramos-Heinrichs, Sandra Garzon) — 27 Comments

  1. I love the idea of this assessment! We frequently use the OASES during annual re-evaluations, but the BSR will be helpful to do intermittent “check-ins” for patient feelings and progress. Actively assessing a patient’s feelings can help us tailor treatment programs to facilitate confidence, acceptance of the patient’s fluency, and encourage “open stuttering.”

    • Hi, Leslie. Thanks for sharing insight in your approach to diagnostic treatment of clients who stutter.

      I have consistently received positive feedback from my clients when engaged in the use of clinical self-reports as part of their treatment.

      If you use the BSR, we are eager to hear your feedback. Let us know how it is working for you.

  2. Greeting Lourdes and Sandra!

    I am a first year graduate student studying Speech and Language Pathology. This upcoming Spring, I will be taking a Fluency course and clinic. As a student learning about different assessment tools, I really enjoyed reading your article and found it very informative.
    What struck me most about the BSR assessment scale is how useful it is in keeping therapy and desired outcomes client-centered. The data collected with this tool reminds the clinician that their client who stutters has unique experiences that shape their perspectives on stuttering.
    As I move into my Fluency clinic I look forward to possibly using this tool if appropriate. With that being said, in order to fill out the BSR how old should the client be?

    Thanks again for posting!!

    • Hi, Katelyn. We are grateful for your thoughtful comments and question about the BSR.

      It is wonderful that as a first year graduate student, you are contemplating therapy approaches that engage the client in his/her own treatment. I have successfully used the BSR with Middle School, High School, and adults. The younger clients may need help from you to fill out form the first few times.

      We’d love to hear feedback on your experiences with the BSR if you ever use it in your clinical practice. Hope you enjoy your Fluency course and clinic in the Spring semester.

    • Hi Katelyn,

      Thanks for your comments on the scale. The scale is most appropriate with middle school, high school students or adults but you can definitely attempt to use it with younger students. The clinician might have to scaffold the questions, specially on the section “Beliefs, attitudes and emotions” or not apply all of them, for example, the client’s self-perception at the work place. We would love to have feedback on the application of this tool. Thanks for your thoughtful comments.

  3. Lourdes and Sandra
    I am a second year graduate student currently working in the schools with a number of Spanish speaking students. I really enjoyed reading about your assessment tool and think it would be something I could use with my students. I was also wondering how you use it with younger students or if you need to wait until a certain age? I also wanted to know the frequency with which you use it?
    Thank you,
    Zoie

    • Hi Zoie,

      We are excited that you are considering using this tool with your Spanish speaking students. Yes, the younger kids might need help to tackle some questions depending on their level of language comprehension or/and insight of his fluency difficulties. There are some questions that might need scaffolding for the younger kids. We have not thought about the frequency of using the scale and we would love to hear feedback from people as they begin to use it. Thanks for posting!

    • In my practice, I used the BSR regularly, at least once per week, at beginning of each session, to check in with client to see how he/she is responding to therapy or to find out if there are any new issues emerging or old issues waning. Only the first few weeks take investment of at least 15 minutes of therapy time; later on, the BSR can be quickly reviewed at the beginning of therapy to check for changes in responses to therapy. I typically bring out the previously filled out BSR and ask the client to review responses, especially the concerning ones, and to reassess his/her current situation, and based on responses, the therapy goals can be adjusted to address current needs. Hope this helps. Thanks.

  4. Hello Lourdes and Sandra,

    Thank you for sharing this valuable tool. It is wonderful to see more resources being developed for bilingual clients!

    I was wondering whether you had any recommendations for collecting more specific information from clients who tend to choose the midpoint, i.e., 3, as their response. I know that in general, when faced with a Likert-type scale, people may end up picking the midpoint when they’re thinking “Well, it depends,” “I’m not sure,” “not applicable,” or any number of other responses that don’t correspond to the other points on the scale. Do you recommend any approaches to clarifying this middle ground?

    Also, I noticed that the anchor points on your scales are either fluent/dysfluent or never/always, depending on the item. For items such as “In my opinion people who stutter are incompetent” and “I should be able to control my speech,” do you still mean to gauge frequency, or the extent to which the client agrees/disagrees with the statement?

    Thank you again, and I look forward to reading your response!

    • Hello Hoi,

      Thanks for raising these important points. In regards to your questions, this scale is definitely a work in progress. In a future publication, we will incorporate your suggestions, which would improve the usability of the instrument. The authors had extensive conversation on the idea of adding more description to the scale in between the anchor points. That would minimize the ambiguity in the ratings. We chose to publish it the way it is for now, but will revise it according to feedback we get from SLPs. BSR users should feel welcome to adapt the scale to meet their particular needs. We love to receive more suggestions to improve the scale. Thank you!

  5. Thanks for sharing your scale. It looks similar to rating scales that I designed for my own use with bilingual clients as well as monolingual clients. I appreciate your inclusion of items related to feelings and attitudes. I have found it useful to have clients use similar questions to rate their own stuttering behaviors as well. Comparing ratings across languages was often useful. It helped us pinpoint issues related to language structure, as and identify situational and pragmatic differences that may also account for differences in fluency between the two. I often rated the same speaking situations as the clients rated; then clients could compare their ratings with mine, and discuss similarities and differences with me. That strategy helped clients improve their self-awareness, as well as their understanding of what I was observing. I learned about their concerns, and they learned about my concerns.

    • Thanks for sharing your thoughts about the scale. We hope to continue finding ways to use the scale in bilingual clients. Perhaps the scale will give us more insight of the challenges the client faces when using one language or the other. Thanks for you’re your feedback.

  6. Hello Lourdes and Sandra,

    I am a first year graduate student currently enrolled in a Fluency course. I also studied Spanish as an undergrad, so I am always interested in learning more about bilingual speech therapy! This seems like a great tool for bilingual clients who stutter. I like the idea of using this scale at each session to check in with the client. My question is do you use this exclusively with bilingual and Spanish speaking clients or do you use it with monolingual, English speaking clients as well?

    Thank you,
    Whitney

    • Hi Whitney,
      It is exciting that you are preparing to be a bilingual English-Spanish SLP. The scale addresses critical aspects of stuttering treatment that could be applicable to bilingual English/ Spanish speakers but it could be applicable also to Spanish speakers only or English speakers only. We hope to get more feedback of the application of the scale for each of these groups. Thanks for posting!

  7. Throughout my grad school experience, I have recognized the importance of being flexible as a clinician in order to meet the needs of the client. Many times a lesson plan might be designed for that day; however, due to events of the week or a client’s current performance on that particular day, a change in plans might be warranted. This flexibility and willingness to adjust plans according to the client’s needs is key to providing effective treatment. I love that the BSR allows us to do just that! I can see how this self-report would enable us to better know how that client feels regarding their fluency on that particular day as well as their progress or frustration since the last session.

    • Thanks for your feedback. We hope you can use the tool with your future clients. Thanks for posting.

  8. Hello Lourdes and Sandra,

    Thank you for such a thoughtful approach to address the bilingual client perspectives within stuttering therapy. As a graduate student in the field of Speech-Language Pathology, I can definitely see how this clinical tool would allow for clients to visualize the significance of their perspectives within the intervention process. When it comes to intervention approaches, which stuttering intervention approach have you found works best when incorporating the BSR? I know most stuttering interventions address the feelings and beliefs of an individual client, but some may have more emphasis on the emotional aspect (like Avoidance Therapy). Have you found more of a successful application of the BSR with fluency shaping or stuttering modification approaches? Again, thanks for sharing such a great resource!

    • Yes, flexibility and willingness to adjust goals in treatment are both critical for successful therapy outcomes. The self-report is client’s guided. As clinicians, we should help the client discover progress and/or the need to target goals that we would only know if the client would communicate to us. Thanks for posting.

  9. Good morning Lourdes and Sandra,

    I am a post-baccularette student currently taking a Voice and Fluency course. I took interest in the bilingual and multicultural aspect of therapy because of my upbringing in a bilingual household. Have you used this tool or modified it to accommodate clients of non Spanish-speakers? If so, how did you modify this tool to meet the language needs of the client? Thank you for creating a wonderful tool for clinicians to help Spanish-speaking clients. I hope to use this tool during my graduate program years and future clinical practicum.

    • Hi Barbara,

      It is great to see that more bilingual professionals take the stand to learn more about how to best serve our bilingual clients. As we have said in other postings, this tool is in working progress and we would like to know of someone applying it in another language. Thanks for posting.

  10. Good evening,

    Thank you for the introduction to the BSR. I am a first year graduate clinician and have not had the opportunity to work with PWS. I like that the BSR gives the client a different way of expressing their thoughts and feelings other than spoken communication. This would be a great tool to use to tailor therapy sessions to the clients needs.

    • Hi Sam,

      We definitely see how the BSR can expand the assessment of the OASES, given that the scale attempts to validate the client’s perspective of his/her stuttering experience. The questions addressed in the BSR pinpoint the affective, behavioral and cognitive components of the overall stuttering experience. I believe the application in other languages is possible. We would be excited to know of someone applying it in another language. Thanks for posting.

    • Hi Nadezhda,

      We hope you can apply this tool with your PWS clients in your future training. We are happy to see that graduate students are looking at treatment in a more holistic manner. Thanks for posting.

  11. This is a great scale for a population that truly needs more examination on either side of their language. It is so important because bilingual speakers tend to demonstrate more difficulty than monolinguals in their language production, and in the example you gave of “‘So how is it going?’, and client responds, “It’s going good.”. This dialogue may be followed by the therapist saying: ‘Good job!'” I think this is universal positive reinforcement, and as someone in a country/place where they have to look for words in different languages we all know this can be extremely difficult. I really enjoy the emphasis on the positive, or expanding their attention on what they are doing correctly.

    I was wondering about if the scale were just Spanish/English or if there is any other languages it could be applied to, perhaps Arabic, or Hindi? I am also very curious as to how this would help/expand the assessment of the OASES in stutttering, and how you would go about using this data for enriching intervention.

    • Hi Sam,

      We definitely see how the BSR can expand the assessment of the OASES, given that the scale attempts to validate the client’s perspective of his/her stuttering experience. The questions addressed in the BSR pinpoint the affective, behavioral and cognitive components of the overall stuttering experience. I believe the application in other languages is possible. We would be excited to know of someone applying it in another language. Thanks for posting.

  12. Hi Lourdes and Sandra,

    Thank you for sharing this. My name is Ana Maria and I am a first-year student studying Speech and Language Therapy (Speech Pathology) at Birmingham City University in the UK. We are studying the Concept of Fluency at the moment and I found the above information really helpful in learning more about Spanish-speaking clients, their stuttering experience and client-centered therapy. The BSR as a clinical tool seems really supportive. Muchas gracias por compartir esta información con nosotros.

    • Thanks, Ana Maria. We appreciate your post. The BSR helps the client to tell his/her own personal narrative about his/her own stuttering experience; and it helps the SLP to stay focused on guiding the client through the self-discovery process. Gracias de nuevo, Ana Maria, y mejores deseos en tus estudios universitarios en UK.