Stuttering Intervention and Professional Preparation: From Both Sides Now (David Shapiro)

About the author: davidDavid A. Shapiro, Ph.D., CCC/Speech-Language Pathology, is a Fellow of the American Speech-Language-Hearing Association, a Board Certified Specialist in Fluency and Fluency Disorders, and the Robert Lee Madison Distinguished Professor at Western Carolina University (Cullowhee, North Carolina, USA). For 39 years, Dr. Shapiro has taught workshops and presented papers, provided clinical service, and conducted research on six continents. His book, Stuttering Intervention: A Collaborative Journey to Fluency Freedom (2nd ed., 2011, PRO-ED, www.proedinc.com) 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 Award of Distinction for Outstanding Clinician, and served as IFA’s President from 2012-2014. Most recently, Dr. Shapiro received the 2016 Oliver Max Gardner Award, the University of North Carolina Board of Governors’ highest honor for faculty in its 17-campus system. Dr. Shapiro is a person who stutters, has two adult children with his wife, Kay, and lives near the Great Smoky Mountains National Park.

Workers in every phase of the helping professions recognize that the client-clinician relationship is a, if not the, crucial variable in the treatment process. (Emerick & Hood, 1974, p. vii)

Methods and materials used in therapy remain insignificant until touched by a spark, the individual clinician’s uniqueness, which elevates them beyond the commonplace. (A. T. Murphy, 1974, p. 30)

The objective of supervision is to develop independent professionals who can provide optimal services to individuals who have communication disorders. (Anderson, 1988, p. 12)

This paper acknowledges the shortcomings in preparing speech-language pathologists (i.e., clinicians, SLPs) to work with people who stutter (i.e., clients, PWS), reviews an experience of clinical service and professional preparation at a university setting during fall 2015 and spring 2016 that brought about client and clinician success, and presents candid reactions and insights from both teens and young adults who stutter and the graduate student clinicians who treated them. Those reactions reveal the respect, dignity, and recognition – indeed the pride – of and by each other and demonstrate how each contributed to each other’s understanding of stuttering and the uniqueness of the stuttering experience.

An Ideal Objective

At the heart of the clinical process are universal stories of human challenge yielding to human triumph. Pursuing fluency freedom provides PWS and their clinicians an opportunity to learn and grow together. Fluency freedom enables PWS of all ages and abilities to consider avenues that heretofore were unimaginable. This is the end goal.

Reality

Recurring observations indicate that SLPs have little experience interacting with PWS, feel inadequately prepared for stuttering treatment, hold negative attitudes toward stuttering and PWS, and experience discomfort anticipating such clinical interactions (Bloodstein & Bernstein Ratner, 2008; Cooper & Cooper, 1985, 1996; Guitar, 2014; Manning, 2010; Tellis, Bressler, & Emerick, 2008). Not surprisingly, PWS occasionally indicate that SLPs fail to understand the feelings and personal experiences of their clients and are not aware of their own negative attitudes toward PWS (Corcoran & Stewart, 1998; Shapiro, 2011; St. Louis, 2001). Making matters even more challenging, changes in the American Speech-Language-Hearing Association’s (ASHA’s) requirements for professional preparation rendered greater flexibility for universities to design their academic and clinical curricula. In practice, however, some programs cut back on coursework and clinical training in fluency disorders, a designation erroneously referred to as “low incidence.” Thankfully, positive changes are occurring today as opportunities for professional preparation of student clinicians and continuing education for SLPs have significantly expanded.

Clinical service and professional preparation can be integrated, enabling student clinicians and their clients each to achieve the end goal. As stated, sharing such an example is the purpose of this paper, leading to a series of questions for related discussion.

The Clients’ Experience: Combining Self-Help and Modified Direct Treatment

Self-help, advocacy, support, or mutual aid groups for diverse concerns have been organized for many years. The earliest self-help groups began among ethnic communities in the USA in the mid-1800s. The first nationally recognized self-help group for PWS was the Council of Adult Stutterers, formed in 1965, at Catholic University in Washington, DC. Yaruss, Quesal, and Reeves (2007) presented a comprehensive review of self-help groups as an adjunct to stuttering therapy, addressing key goals and recommendations for participants including adults, teens, and children who stutter, in addition to parents and SLPs.

The self-help group described here enabled teens and young adults who stutter to discuss topics related to communication and life and engage in activities with others who had experiences that in ways were similar and in other ways were different. The clients decided the topics and activities and elected to receive modified direct treatment from the graduate student clinicians and the clinical supervisor (i.e., the author) as part of the group experience. Meetings occurred once per week for 1.5-hour duration.

The clinical process deliberately focused on collaboration (engaging in all aspects of the treatment process together, including planning, evaluating, and follow up), success (designing activities for – and later with, and eventually by – the clients so that each experiences improvement at every stage of the communication hierarchy as jointly designed, thereby yielding continued motivation and communication independence), and fun (genuinely enjoying the personal interaction and all treatment-related activities). Nothing is as motivating as success itself. Procedures included creating a “safe house,” tailoring to the strengths of each client, heightening the client’s awareness of his speech fluency, inviting objectives from the client, improving fluency facilitating techniques, addressing feelings and attitudes directly, facilitating transfer from the beginning, preparing for relapse, engaging the client and family as active members of an interdisciplinary team, and more (Shapiro, 2011). As a consequence of this process, mutual growth occurs and genuine bonds of collegiality and friendship are formed. It is not unusual to see candid emotional expressions, including laugher and occasionally tears.

The Graduate Student Clinicians’ Experience: Merging Classroom Instruction, Clinical Practice, Supervisory Conferences, and Applied Research

Five first-year graduate students completed a three-semester hour graduate seminar (Fluency Disorders, 16 weeks) during their first semester (fall 2015) at the Western Carolina University and then served on a treatment team during their second semester (spring 2016). The seminar and treatment team were coordinated by the author. The topics and projects in the seminar addressed but were not limited to:

  • Theoretical and research foundations of fluency disorders, and how these inform current assessment and treatment methodology,
  • Onset and development of stuttering from both developmental and longitudinal perspectives, and the nature and etiology of stuttering,
  • Other fluency disorders with comparison and contrast to stuttering,
  • Guiding intervention assumptions including intrafamily (i.e., personal constructs and family systems), extrafamily (i.e., interdisciplinary teaming and multicultural awareness), and psychotherapeutic (i.e., stuttering modification and fluency shaping) factors,
  • Necessary components of an assessment and treatment plan for preschoolers and school-age children, adolescents, adults, and senior adults who stutter,
  • Characteristics of the clinician and client-clinician relationship that are necessary for effective assessment and treatment,
  • Components of professional preparation and lifelong learning for clinicians who specialize in fluency intervention, and
  • New and emerging treatment strategies, evidence-based practice and evaluation of treatment outcomes, the value of self-help and mutual aid, clinical training and specialization, and global perspectives on the nature and treatment of stuttering.

The clinicians met in a supervisory conference once per week for at least one hour. Meetings initially were structured by the supervisor, but quickly were structured by the clinicians. Earliest meetings reviewed goals and expectations for and of the clinicians and the clients. Each clinician prepared an individual professional development plan to chart her own growth (i.e., delineating existing professional knowledge and skills and objectives for measureable professional growth) and an applied research proposal, which led to completion of individual pilot projects. The clinicians created a rotating system for handling clinical responsibilities (e.g., designing clinical activities and lesson plans, collecting data, completing required paperwork for accountability, collating and monitoring self-help activities initiated by the clients, and more). Emphasis was placed on clinical application and affective, behavioral, and cognitive growth of all involved – clients, clinicians, and the supervisor. Professional growth was documented on the bases of movement along the continuum of professional development, whereby each clinician progressed from receiving direct evaluation and feedback, to a transitional phase requiring less direct input from the supervisor, to eventual self-supervision. To accommodate the clinicians’ professional growth, supervisory styles transitioned from direct or active, to collaborative, to consultative (Anderson, 1988). Similarly, changes in the clinicians’ skills were observed, including:

  • Perspective shifts (i.e., from their own perspective to the client’s),
  • Dimensions conceptualized (i.e., from the client’s stuttering behavior only to the client’s thoughts and feelings as well),
  • Activities and intervention methods generated (i.e., from their own ideas only to that of the clients, from the supervisor’s method only to their own with clear clinical and theoretical rationale), and
  • Causal conceptualizations considered (i.e., becoming increasingly comfortable drawing from the existing literature and evidence basis to design and initiate original plans, branching out from the specific ideas and methods taught in the seminar). (Shapiro, 2011)

The clinicians and clients described their own perspective on the experience and the resulting progress, as follows:

Clinicians’ Views

Amanda:

“As a person who has never stuttered, I initially felt defeated when I began my first clinical rotation with PWS. It seemed impossible to understand their thoughts and feelings. If I couldn’t understand, how could I help? However, as I gained both knowledge in the classroom and experience in the clinic, I learned that competence as a clinician isn’t limited to personally having experienced a fluency disorder. The way therapy is provided is at least as important. Individuals who stutter need to feel valued, heard, and befriended, whether we have had similar experiences or not. The confidence I gained required a process that took time. Classroom knowledge, a beautiful supervisory example, and immersing clinically and applying information and evidence all guided my learning. I was privileged to experience for myself the freedom and joy that comes from knowledge and clinical application.” 

Lauren:

“Working with Dr. Shapiro and the fluency group, I gained so much knowledge. Professionally, I collaborated with other clinicians and PWS, shared diverse ideas, and decided on the best approach to ensure our clients’ success. I gained a better understanding of the nature of stuttering and how to design, implement, and monitor fluency treatment. Personally, I gained the ability to trust myself as a clinician and to trust my clients, as they are the most knowledgeable about their own communication experience. They can become their own best advocate; they can be the clinician’s best teacher.”

Christine:

“My experience with the treatment team was invaluable. There is no greater excitement than listening to your client use fluency controls on a difficult word and observing his confidence that results. I was one of five graduate clinicians on a collaborative treatment team that worked closely with the clients and professor. We met regularly, borrowed from the literature, and implemented each session with our own ideas. Our supervisory conferences were motivating and participation was natural because everyone’s voice was heard. I now feel confident to provide fluency therapy because my first experience was a successful team effort.  I recommend combining self-help with group therapy and collaborating with a treatment team to any clinician!”

Candice:

“Student clinicians are expected to apply classroom knowledge in the clinical setting. With Dr. Shapiro, we did this and more. We learned the importance of personal constructs for both clients and clinicians and how to design and implement treatment within this framework. Without the benefit of the seminar on fluency disorders and Dr. Shapiro’s textbook, I would not have been prepared for practicing as a student clinician. I would have been focused only on the behaviors of PWS, rather than addressing the affective and cognitive aspects of communication and the client-clinician relationship.”

Katrina:

“Participating in Dr. Shapiro’s fluency intervention group enabled me to learn the fundamentals of fluency therapy. From building relationships with the clients to designing intervention activities, the experience showed me how to approach fluency therapy holistically. While encouraging the clients to open up and reflect on their emotional progress, I pushed myself to reflect on my own insecurities and anxieties, resulting in personal growth and increased empathy towards PWS. Although I still have much to learn, this experience left me feeling confident in my ability to work with adults who stutter and collaborate with fellow clinicians.”


Clients’ Views

Javan:

My speech and I have had a complicated and challenging relationship. The transition from high school to college didn’t make things any better between us. Seeking help was the best decision I’ve ever made. My first year of speech therapy was eye opening. The most crucial thing I learned is the importance of awareness as a communicator. My ears are trained to hear both the fluency and disfluency while I talk. I believe this skill is vital because once you detect fluency, you can maintain it; once you detect disfluency, you can use reliable controls in the moment. After a year of therapy, I now have a thorough understanding of my speech and the confidence needed to be an independent communicator in this world.”

Joao:

“Two years ago, my speech was full of disfluencies, which negatively impacted my social life and lowered my self-esteem. It didn’t take long in the group to regain my fluency and self-esteem. I learned the importance of having confidence in myself and not being scared to say what I want. That is key to being an effective communicator. Now I speak to large groups of people with no problem. Social interaction has become easier. Talking on the phone and ordering fast food aren’t an issue anymore. The main reason for such success is the way the clients are approached. The clinicians and Dr. Shapiro are very well prepared. They always have great ideas and they invite our own so that we can help ourselves. Therapy creates a link of friendship and trust between the clients and clinicians.”

Taylor:

“Each morning when I awake, I have a set of fluency freedom tools at my fingertips that I can use to accomplish my daily communication tasks. No longer do I have to hide in silence! While my speech may not be flawless, I have what I need to control my speech. Dr. Shapiro has instilled in me that my speech does not have to be perfect, yet I should strive to be in control. I am now able to fulfill my lifelong dream of practicing as a healthcare professional, having just completed my Doctor of Physical Therapy degree, and helping patients daily with my controlled speech. This would never have been possible otherwise.” 


Summary and Questions to Consider

There are as many methods for stuttering intervention and professional preparation as there are people who stutter and clinicians. The objective of both is clear: To enable each person to realize her or his own best potential. As we attempt to achieve this objective, we might consider questions that were raised by the student clinicians:

  • What role does faith play within the clinical context? In what ways might the client’s faith in the clinician lead to communication success? (Amanda)
  • How does the client’s experience of regular success within treatment contribute to a more positive treatment outcome? How might clinicians construct such successes? (Lauren)
  • In what ways might PWS interpret humor differently than people who do not stutter? (Christine)
  • How might the benefits of self-help, group treatment, and their combination be maximized for the success of each PWS? (Candice)
  • In what ways do personal and social anxiety contribute to the communication experience? How can SLPs best support their clients when such anxiety exists? (Katrina)
  • What methods of professional preparation best prepare clinicians to understand the uniqueness of stuttering and to work most effectively with PWS across the lifespan? (DAS)

References

Anderson, J. L. (1988). The supervisory process in speech-language pathology and audiology. Boston: Little, Brown/College-Hill.

Bloodstein, O. & Bernstein Ratner, N. (2008). A handbook on stuttering (6th ed.). Clifton Park, NY: Thomson/Delmar Learning.

Cooper, E. B., & Cooper, C. S. (1985). Clinicians attitudes toward stuttering: A decade of change (1973-1983). Journal of Fluency Disorders, 10, 19-33.

Cooper, E. B., & Cooper, C. S. (1996). Clinicians attitudes toward stuttering: Two decades of change. Journal of Fluency Disorders, 21, 119-135.

Corcoran, J. A. & Stewart, M. (1998). Stories of stuttering: A qualitative analysis of interview narratives. Journal of Fluency Disorders, 23, 247-264.

Emerick, L. L., & Hood, S. B. (1974). Preface. In L. L. Emerick & S. B. Hood (Eds.), The client-clinician relationship: Essays on interpersonal sensitivity in the therapeutic transaction (pp. vii-viii). Springfield, IL: Thomas.

Guitar, B. (2014). Stuttering: An integrated approach to its nature and treatment (4th ed.). Baltimore: Lippincott/Williams & Wilkins.

Manning, W. H. (2010). Clinical decision making in fluency disorders (3rd ed.). Clifton Park, NY: Delmar/Cengage Learning.

Murphy, A. T. (1974). The quiet hyena: Two monologues in search of a dialogue. In L. L. Emerick & S. B. Hood (Eds.), The client-clinician relationship: Essays on interpersonal sensitivity in the therapeutic transaction (pp. 29-44). Springfield, IL: Thomas.

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

St. Louis, K. O. (2001). Living with stuttering: Stories, basics, resources, and hope. Morgantown, WV: Populore.

Tellis, G. M., Bressler, L., & Emerick, K. (2008). An exploration of clinicians’ views about assessment and treatment of stuttering. Perspectives on Fluency and Fluency Disorders, 18, 16-23.

Yaruss, J. S., Quesal, R. W., & Reeves, L. (2007). Self-help and mutual aid groups as an adjunct to stuttering therapy. In E. G. Conture & R. F. Curlee (Eds.), Stuttering and related disorders of fluency (3rd ed., pp. 256-276). New York: Thieme.

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Comments

Stuttering Intervention and Professional Preparation: From Both Sides Now (David Shapiro) — 28 Comments

  1. Hello David,

    From both personal experience and from reading the literature, I know our profession is filled with clinicians who feel unprepared to work with people who stutter. As one who walks both sides of the line, as a clinician and PWS (and your student seemingly an eternity ago!), it warms my heart to read how young clinicians at my alma mater are being so well prepared to meet the challenge. The kind of holistic and collaborative therapy you describe represents a community of support in which reinforcements are built in, motivation soars, and success is achieved. I feel so optimistic about the future of our profession when I read Javan’s comment that “Seeking help was the best decision I’ve ever made.” Well done. Warm regards,

    Rob

    • Hi Rob, Thank you for your kind thoughts, as always, and for summarizing the instructional mission I strive to achieve. And it is so exciting for me to see you, a former student and now professional colleague, making such significant contributions to our field of Communication Sciences and Disorders. Ours is such a rewarding profession; I am so glad that you are in it. You are long due for a visit to this side of the state; give a yell anytime. Kind regards, David

  2. Hi David – I have recently had the honor of speaking with speech therapists from several large school districts in my area. The overwhelming feeling confirms your comments about therapists being unprepared and uncomfortable with treating children who stutter, especially young children. You state that you addressed “Necessary components of an assessment and treatment plan for preschoolers and school-age children…” How are the components are for preschoolers and school-age children similar or different from those for adolescents and adults? Can you share feedback from your clinicians, clients, and their parents about treatment experiences of this younger population? Thank you.

    Dori Holte

    • I want to clarify — the therapists I met with clearly expressed their feelings of feeling unprepared and uncomfortable, especially with using speech tools and techniques to lower %SS, and most were not prepared with other options. That wasn’t just a feeling I got from talking with them.

      Dori

      • Hi Dori, You are asking an important and complex question. My response here can only begin to scratch the surface, however. A more complete response is what we strive to achieve throughout graduate student clinicians’ professional preparation. As a part of the Fluency Disorders Seminar, we focus on precepts for each group (i.e., acknowledging that each individual may or may not reflect group patterns); preassessment, assessment, and post-assessment procedures; and treatment goals, objectives, rationale, and procedures. For preschool children, we address stages of play, as well as forms of parent intervention and more direct intervention, each with affective, behavioral, and cognitive objectives and procedures. For school-age children, as well as more directly for adolescents, adults, and senior adults, we address two primary goals (i.e., spontaneous or controlled fluency and establishment or maintenance of a positive attitude toward communication and oneself as a communicator), four primary objectives (establish or increase and transfer fluent speech, develop resistance to potential fluency disrupters, establish or maintain positive feelings about communication and oneself as a communicator, and maintain the fluency-inducing effects of treatment across time and place on communication-related behaviors, thoughts, and feelings), and seemingly countless related procedures. Each section is related to and inclusive of other participants (parents, teachers, families, allied professionals, etc.) and is grounded on what is known and not known about communication, communicators, and communication disorders, particularly stuttering (i.e., onset, nature, and development from developmental and longitudinal perspectives), past and present explanations of etiology and theoretical interpretations, differential diagnosis, as well as central and guiding intervention assumptions (intrafamily – personal constructs and family systems, extrafamily – interdisciplinary practice and multicultural awareness, and psychotherapeutic- fluency shaping and stuttering modification). I can only imagine how circuitous – or dense – this reply must seem. I remember you indicating from previous interaction that you have reviewed my book. You may want to take a closer look at the second edition (Stuttering Intervention: A Collaborative Journey to Fluency Freedom, 2011, http://www.proedinc.com) or contact me outside of this forum for a more detailed discussion. I always enjoy your insights and our interactions. Kind regards, David

  3. Dr. Shapiro,

    I am currently a second year SLP student at Idaho State University. I was told during my first year that research shows that when SLPs graduate they often feel the least prepared to work with PWS. I was given the opportunity to participate in the NWCFD-IISC this past summer and am so blessed I had that experience while I was in graduate school. I really enjoyed reading through this presentation and the efforts you have taken at your university to prepare future SLPs to work with PWS. I particularly enjoyed reading through both the clinician’s and client’s perspectives about the fluency group. I agree with Rob on feeling more optimistic about the future of our profession and an increase in confidence when working with people who stutter. Thank you for sharing.

    • Thanks for your kind thoughts. Yes, there is much we can do within professional preparation to help clinicians realize that working with PWS and their families is a joy and an opportunity to learn and to grow together. I’ve only been doing this for 40 years. I am probably more excited now as a clinician than I was when I first began. I know you’re in good hands with Dan Hudock. With positive influences like his and can-do approaches like yours, I know we’re facing a positive future, both for PWS and SLPs. You may or may not know that you are about to enter one of the most fascinating and rewarding professions. Good luck. DAS

  4. Dr. Shapiro,

    I am currently a second year graduate student at the University of Minnesota Duluth. While my graduate program does include two Fluency related courses (Intro to Fluency Disorders, and Advanced Fluency). I love that my university provides in-depth coursework on fluency and fluency disorders, and hope that I have the opportunity to apply the treatment methods that we have discussed in my clinical internship experiences so that I feel fully prepared to use them once I am a practicing SLP. Reading this article did bring up some questions: do you think, or have you noticed, the gender or age of the clinician/client could hindering the SLP from creating the type of meaningful and “friendship-like” bond needed to create a positive therapeutic outcome that you reference in this article? For example, do you think that an 18-year old, male, covert PWS would have more success with a younger SLP, rather then an older one because they feel they can relate to and trust the younger one more? What, if any, affect do you think this has on the therapy that clinicians are currently providing?

    • Hi Kelsey, Your question is interesting. Honestly, I have not noticed gender or age of the clinician to be an inhibiting factor at all. Rather, by constructing for (i.e., and soon with, and eventually by) the client opportunities for him/her to experience success, the client seems to rally around and relate to the process and its participants. Another factor is the extent to which the clinician can relate to aspects of communication and life relevant to the client’s experience that the clinician might not have experienced personally. What I am suggesting is that more primary factors impacting the nature of the clinical relationship might be the extent to which the client experiences success for himself/herself and the clinician’s interpersonal and intrapersonal characteristics (i.e., that are reflective of effective clinicians; you might wish to take a look at my book, Stuttering Intervention: A Collaborative Journey to Fluency Freedom, 2nd ed., 2011, Chapter 11 – The Clinician and the Client-Clinician Relationship, for a review of such factors). That said, no doubt there are many other factors, including age and gender, in addition to educational level, culture, socio-economic status, professional standing, perceptions of safety, power, etc. that could be operating as an interpersonal dynamic. Your question, and ones like it, are inviting in that they could be addressed empirically. BTW, you’re about to enter one of the most wonderful professions. Prepare for this lofty role and serve as if there is no tomorrow. This work is a calling and a vehicle for you to leave your positive imprint in such a way that communication and communicators, both local and global, are better for it. Good luck. DAS

  5. Dr. Shapiro,

    I am currently a second year graduate student at the University of South Carolina. A few of my colleagues and I read your article, and could definitely relate to the feelings of inadequacy when working with PWS as a clinician. Working with any client can be very nerve racking for a young clinician, especially if it is your first time with a particular disorder. We were particularly intrigued by your student Amanda, and the comment she made about what role faith plays in our current practice with PWS. This led us to wonder about the role that our anxiety and uncertainty play in our therapy sessions. We discussed our fears about working with PWS, which led us to wonder how that affects the success of our clients. We all agree that with more education and practice we can become more confident in our skills, which may lead to a reduction in anxiety on our end. We feel as though this may have a reciprocal effect and ultimately lead to a more successful intervention.

    Thank you for your thoughts on this topic.

    Best,

    Lena Martone, Holly Linville, Phillip Levkoff

    • Thank for your kind words and for sharing your thoughts. Yes, fear and anxiety are natural in the early phases of clinician development and part of becoming a confident and competent clinician. One of the best antidotes to fear and anxiety is success. Just as the client benefits greatly from experiencing success, the clinician becomes more confident and less fearful and anxious as s/he accumulates a foundation of success. In other words, success begets success. As a supervisor, this is what I try to do for my student clinicians. Quickly they begin to design such opportunities for themselves. Indeed, there are parallels and interconnections between and among the academic, clinical, and supervisory processes. And yes, I too am so intrigued by Amanda, as well as the other students I highlighted. You may want to take a look at Amanda’s paper, posted in this forum just above mine (http://isad.isastutter.org/isad-2016/papers-presented-by-2016/research-therapy-and-support/faith-and-fluency-inviting-a-closer-look-amanda-glover-david-shapiro/). You’ll note from my earlier posts that I believe you are about to enter one of the most wonderful professions. You are the next generation and we need you in this field. Keep making such good connections and good insights. PWS, their families, and CSD are counting on you! Good luck. DAS

  6. Dr. Shapiro,

    I am currently a second year graduate student. I am enrolled in a Fluency Disorders course and we are spending a great deal of time learning how to treat stuttering. Like many of your graduate students, I feel as if I will still be very nervous and uncertain when I do have a client who stutters since I have never been exposed to the disorder outside of coursework.

    As far as professional preparedness, what are the most important things to consider while starting out as a new clinician working with PWS?

    • Hi Haylee, What a good question! Sometimes clinicians become anxious when they think they need to know it all or to control the interaction. Actually, neither is the case. Treatment essentially is a focused conversation (in which objective data addressing communication-related thoughts, feelings, and behaviors are collected) and an opportunity to learn from the PWS about the uniqueness of his or her own experience. It is a time to see through the eyes of the client to experience his or her world for the brief time you are together. What a joy; what a privilege to learn and to grow together! Who is more expert about oneself, one’s world, and one’s communication experience than the client? Also, novice clinicians often believe that they need to provide treatment directed at the client. Rather, our objective is to create opportunities for the client to experience success. This responsibility deliberately shifts, such that the client and clinician soon design such opportunities together, and not long thereafter by the client alone. The same shift of responsibility should be seen with other aspects of the treatment experience (e.g., monitoring progress toward individualized objectives, use of fluency facilitating controls, maintaining a positive outlook toward communication and oneself as a communicator, transfer of communication skills over time and place, etc.). Years ago, Van Riper suggested that the clinician know himself/herself well before ever interacting with a client. This is good advice. You might find the continuum of professional development to be helpful (Anderson, 1986; reviewed in my book, Stuttering Intervention: A Collaborative Journey to Fluency Freedom, 2nd ed., 2011, Chapter 12). That certainly speaks to the ongoing process of learning and development of clinical expertise. Finally, know and embrace the opportunity to make a meaningful difference in the world of others. As you’ve seen from several of my previous replies, prepare and serve as if there is no tomorrow, over the long haul. Good luck. DAS

  7. Hi Dr. Shapiro,

    I am a graduate student as well as an SLPA who works at a fluency clinic. Because a majority of my direct experience in this field so far has been with fluency, it has been very interesting to me to interact with other graduate clinicians, as well as professionals in the field. I have yet to meet an SLP, other than the one that I work for, who is comfortable with fluency. In fact, most of the SLPs that I have met seem to be very uncomfortable with assessing and treating fluency. It was very interesting to read in your post that this is a common characteristic. From discussions that I have had, it appears the most of the discomfort comes from a lack of education in this area.

    Something that I am really pleased about, and that your post really brings to light, is that there seems to be a movement in the field of SLP towards helping clinicians be more effective in treating fluency disorders. I have heretofore taken my experience working with PWS and PWC for granted. I’m glad that many programs appear to be making a real effort toward education.

    Thank you for all of the great information provided in your post!

    Katie

    • Hi Katie, Thanks for sharing your observation and your kind words. Indeed, clinicians’ discomfort when treating PWS is empirically documented. Thankfully things are improving and more resources than ever before are available both for clinicians and clients (PWS and families). Yet we still have much work to do. It sounds like you are gaining valuable experience. Remember always to pay it forward. All of us – PWS, families, experienced and novice clinicians, and allied service providers, among others – all are teachers and learners throughout our lifetime. Good luck as you pursue the career. We need you in this discipline. DAS

  8. Hi David,

    What a great paper. I loved hearing the perspective of both the graduate students and the clients. And of course your perspective on what is really needed to successfully prepare clinicians to work with those of us who stutter. I remember from my days in therapy with graduate students that they seemed so unsure and nervous, several sharing with me that stuttering was the hardest “rotation” to deal with.

    In my own papers on this ISAD conference, I’ve had numerous graduate students ask me what advice I might offer for them as they prepare to work with people who stutter. Some have expressed concern that because they don’t stutter, they may not be able to relate to the client. Others have expressed concern that they can’t possibly know the full magnitude of feelings a person who stutters experiences. I’ve tried to offer up what I think would have helped me when I worked with grad students, as a client of course.

    You have been very encouraging to those about to embark on a very rewarding career. You’ve told students in your comments that they need to go get ’em. I have no doubt your students will be ready to work with people who stutter.

    What would you say is the most challenging part of preparing students to work with stuttering, even after all your years in service to this goal?

    And I still remember the great paper you wrote some years back about The Velveteen Rabbit, and the exchange we had.

    Pam

    • Hi Pam, What a good question! I think one of the most challenging aspects of preparing student clinicians is to combat their temptation to address the behavioral aspect of stuttering only. Indeed, stuttering treatment must address communication-related thoughts and feelings. Similarly, treatment isn’t only about implementing a treatment program, but about helping others to imagine, sometimes for the first time, positive alternatives to what they have always known. As such, intervention is about shared dreaming and enabling others to realize their fullest potential – as communicators and as people. What an exciting process this is and, after 40 years in the field, still a joy and privilege! THAT is what I want student clinicians to realize and to experience during their preparation and during their career. I too remember our exchanges, usually related to ISAD papers. You continue to be so consistent in your positive contribution to the stuttering community worldwide. Thank you for all that you do – I say this both as a PWS and as an SLP. Warm regards, David

  9. Hello Dr. Shapiro,
    I am a second semester graduate student at Appalachian State University and I find this to be such a great idea for graduate students. I am currently in a fluency class and I am learning so much, but it would have been very helpful if I did participate in a 3 seminar my first semester and then was put on a treatment team for fluency my second semester. Throughout my clinical experiences so far, I have only had one stuttering client. So, maybe it is true one does not come across stuttering as often as other disorder. But, my question to you is, what kind of therapy do you believe in for PWS? I have been learning about direct and indirect approaches for stuttering in class and I am curious which one you use more.

    • Hi Julia, As you know, the graduate program prepares you across the “big 9 areas” so that, once you are in the field, you can function independently as a clinical problem solver. That you have experienced only one PWS so far should not suggest that stuttering necessarily is a low incidence disorder. With approximately three million PWS in the USA alone and over 70 million worldwide, that’s a lot of PWS! And what kind of therapy do I believe in for PWS – that’s a big question! In short, the treatment I utilize is tailored for each PWS and emphasizes what s/he already is doing (and thinking and feeling) that is consistent with fluency and communication freedom. Then treatment provides an opportunity for each PWS (and others within the communication system) to experience success and to improve what one already is doing well. There are so many aspects that impact the design of treatment. Figuring this out and, as such, having an opportunity to learn and to grow together, are what makes what we do so exciting, challenging, and fun for all who are involved. For a more detailed review of my own treatment design, you might want to take a look at my book (Stuttering Intervention: A Collaborative Journey to Fluency Freedom, 2nd ed., 2011, http://www.proedinc.com). BTW, you’re in good hands with Dr. Klein at ASU. Warm regards to both of you, DAS

  10. Hi Dr. Shapiro,

    I am in a graduate program and enrolled in a Fluency Course. I currently have one client who stutters, and am working along with my Professor. I was wondering if you had any research articles or resources you could recommend for determining which intervention techniques to begin with when working with a PWS?

    Thank you for your time!

    • Hi Rachel, I am glad to learn that you are enrolled in a fluency course. Having been a professor for many years, for me this always is one of the most exciting and rewarding courses within the CSD curriculum. As to a recommendation for a research article or resource – that is a “tall ask”! If I had to choose one, I think I would suggest Emerick and Hood’s book from 1974 as a starting point – The Client-Clinician Relationship: Essays on Interpersonal Sensitivity in the Therapeutic Transaction. Continue to work hard as you prepare to become an SLP. PWS, their families, and CSD are counting on you! DAS

  11. Dr. Shapiro,

    I am a second year graduate student currently enrolled in a Fluency course. I have not yet had the opportunity to work with a young, school-aged PWS. In my next internship I will be in a elementary school setting and my supervisor’s caseload includes PWS. I am worried that my inexperience providing therapy will create challenges for me when trying to connect with the students and provide therapy. Do you have any advice for me or recommendations for further resources to increase my competency and better prepare myself for providing therapy to these students?

    Thank you for your time,
    -Katie

    • Hi Katie, What an exciting experience for you! I love working with school-age children who stutter. As for a resource to get you started, you might take a look at Dean Williams’ work. For me, he was a master of how to talk with children who stutter about talking. You can check the reference list in the text you are using for your fluency course. FYI, The Stuttering Foundation (http://www.stutteringhelp.org/) distributes some of his work at low cost. Or take a look at the references in my book (Stuttering Intervention: A Collaborative Journey to Fluency Freedom, 2nd ed., 2011, http://www.proedinc.com). You can find a number of his citations there. You’re about to enter one of the most exciting careers. Always do your best so that others can achieve their best. Good luck. DAS

  12. Hi Dr. Shapiro,

    We are second year graduate students at the University of Tennessee. We are currently enrolled in an advanced stuttering seminar class in which we have discussed at length the best way for clinicians to interact with clients presenting with a wide variety of overt and covert stuttering behaviors. I appreciate your emphasis on addressing the attitudes and beliefs of a PWS in therapy because it seems as though that may be just as important, if not more important, than targeting the overt behaviors. Hopefully awareness of this disorder can contribute to a decrease in negative reactions of others to PWS in the future. It appears that there has been a shift in the school systems that places an increased emphasis on acceptance of others, which may reduce the anxiety of the PWS when interacting with peers.

    As future SLP’s we are very interested in the treatment of this disorder, however due to the low incidence rate, many of us will not get the chance to treat a PWS before graduating. Although we have been well educated on treatment methods and theories, we still have the discomfort that comes with treating such a complex disorder. What recommendations do you have for entering a first session with a PWS?

    Thank you so much for your efforts in helping graduate students prepare for treating PWS!

    Sarah Silverii, Elizabeth White

    • Hi Sarah and Elizabeth, Like other good, inquiring student clinicians, you’re sharing important insights and asking good questions. Yes, it seems that there is renewed emphasis on addressing communication-related thoughts and feelings in addition to behavioral aspects of stuttering. Otherwise it is as if we are looking at a piece of the puzzle and trying to figure out where it belongs or how it fits, rather than considering the entire context. And yes, there is renewed emphasis on interacting with the public and peers and disseminating accurate information so as to reduce misinformation and negative stereotype. All of that said, isn’t it intriguing that approaching treatment of people who stutter often is greeted with trepidation, rather than wonder and excitement as an opportunity to learn and to grow together? Your question regarding recommendations for beginning clinicians is a big one. Thinking about how to reply, I just reviewed my responses to previous posts above. Here’s what I’ve come up with so far: Embody a positive, can-do, yet realistic perspective (i.e., recall David Daly’s/1988 discussion of the clinician’s attitude toward the client’s potential for positive change as a primary predictor of treatment outcome); become comfortable with the concept that the client and the client’s family are your teachers and that nothing replaces the significance of the client-clinician relationship; learn how to create opportunities for the client and the client’s family (and for you) to experience success; study and understand the interrelationships between and among the academic, clinical, and supervisory processes; engage in self-study (both you and each of your clients represent a potential case study; evaluate yourself and identify precise objectives for your own professional growth – feel free to review Chapters 11 and 12 in my book, cited in my bio); study and know yourself – your own talents, challenges and needs before meeting with a client; and relish the opportunity to make a meaningful difference in the world and, as a consequence, to grow as a person. Certainly in your advanced seminar you are learning all you can about communication, communicators, and communication disorders (particularly stuttering – onset, nature, and development from developmental and longitudinal perspectives; past and present explanations of etiology and theoretical interpretations; differential diagnosis; and central intervention assumptions: intrafamily – personal constructs and family systems, extrafamily – interdisciplinary practice and multicultural awareness, and psychotherapeutic- fluency shaping and stuttering modification; in addition to diverse assessment and treatment methods for PWS across the lifespan). All of this is important. Know also that there is a continuum of professional development (Anderson, 1988) containing distinct stages and styles of interaction to enable you to progress into a self-supervising, independent, problem-solving clinician. You’re on the right path. BTW, you can find the references I noted above in my book or you can contact me separately. Commit to doing well and doing good. Pay it forward. Love your work and see through the lens of positive possibilities. Be that agent of change who enables someone to imagine, perhaps for the first time, the unimaginable and acquire both the confidence and competence to help him/her make it happen. We need you in this profession. Never take a moment or a person for granted. Learn and serve – everyday – as if there is no tomorrow. Good luck. DAS

  13. Dear Dr. Shapiro,

    Thank you for this article. I felt it was very enlightening to read both the clients and clinicians viewpoints. It amazed me that Javan only needed one year of speech therapy to be in control of his speech. I had figured it would take several years of speech therapy to gain that control. Of course my experience is mainly with children and Javan was an adult which might make the process faster. In your article I loved the sentence that said, “Nothing is as motivating as success itself.” This made me really think about what success is for a PWS. I do not believe it is perfectly fluent speech but enabling them to modify their speech when they desire to. Anyways I feel that I have gained a lot from reading your article.Thank you.

    Kliss

    • Hi Kliss, Thanks for your kind words. I’m glad that you enjoyed the paper and are reflecting on what success means for each individual client you encounter. Also, while there are evidence-based prognostic indicators, I continue to suggest, “Never say never.” Each client may or may not reflect group trends and people continue to defy the odds every day. Be the one who enables PWS to imagine the “impossible” and help each to realize his or her best potential. That is our mission and that is success! Good luck. DAS

  14. Hi David

    As one of your biggest fans, also this year’s paper from you, as well as the papers from your students, hits home. I have had replies to my different papers from SLP students who tell me how much they learn from you, so thanks to you we have so many amazing SLPs. I so hope we can invite you to Sweden, as you would be such an inspiration to both PWS and SLPs here, both as a teacher, an SLP, a PWS and for the person you are.

    Hugs, Anita