Growing together: The importance of the therapeutic relationship in stuttering therapy – Hilda Sønsterud and Kirsten Howells

About the Authors:

Hilda Sønsterud is a speech and language therapist in Oslo, Norway. She works in Statped’s department for speech and language disorders in Norway, and is a PhD-fellow at the University of Oslo. Hilda works primarily with treatment and clinical research related to stuttering and cluttering, and runs courses within the field of fluency disorders. Her PhD project involves a collaboration between the Norwegian Association for stuttering and cluttering, Statped, the University of Oslo, and the University of Reading. The project is a clinical treatment study, focusing on individualized therapy for adults who stutter.
Kirsten Howells is a speech and language therapist in the UK. Within her private practice, she specialises in working with children and adults who stutter, along with their families, teachers and employers.

Introduction

This article describes a recent research project examining the importance of the therapeutic relationship within stuttering therapy. The findings highlight the value of open discussion regarding the goals of therapy and the tasks or activities incorporated within that therapy. Speaking out through open discussion can lead to therapeutic growth and change.

The working alliance

It is likely that the relationship between persons who stutter and SLPs affects the course of therapy and its outcomes. The relationship matters. This importance is acknowledged within wider communities of people who stutter, such as the podcast and online community StutterTalk© which published a statement as follows, “… As the therapeutic relationship is built upon trust and understanding, let yourself ‘shop around’. If you don’t feel comfortable with the first therapist you meet, visit with another” (http://stuttertalk.com/stuttertalk-position-statement-on-self-help-and-speech-therapy-for-people-who-stutter/).

But what is it that makes this relationship between a person seeking support and a therapist successful or unsuccessful? It was Bordin (1979) who first named the relationship the ‘working alliance’. The concept can be described as the degree to which the person and the therapist are engaged in collaborative, purposive work. Flückiger and colleagues describe how ‘The alliance represents a proactive collaboration of clients and therapists across sessions and in moment-to-moment interactions’ (Flückiger, Del Re, Wampold, & Horvath, 2018, p. 330). It has been suggested that the working alliance has its foundation in three processes, described as the bond, the goal and the task. That is the emotional bond between the person and the therapist, the extent to which the person and the therapist agree on the goals of treatment, and the extent to which the person regards the treatment tasks as relevant for that goal (Bordin, 1979; Hatcher & Gillaspy, 2006; Horvath, Del Re, Fluckiger, & Symonds, 2011). Indeed, research within speech-language therapy has demonstrated that an individual’s opinion of treatment as effective or ineffective is influenced by their experience of the collaborative process in clinic (Manning, 2010; Plexico, Manning, & Dilollo, 2005, 2010).

However, although there is already consensus that SLPs should openly and honestly discuss an individual’s goals and expectations for therapy in general, there has been little previous investigation of the impact of personal motivations and the working alliance for people who stutter. Fortunately, over recent years, there has been increasing interest in the therapeutic relationship as an evidence-based component of interventions in speech and language therapy and recent research by our group (Sønsterud et al., 2019) explored this specifically within therapy for stuttering. Our findings suggested that this relationship, the working alliance that grows from describing, discussing and agreeing goals and tasks, is a critical element in successful stuttering therapy.

Based on this research, it is recommended that evaluation of the working alliance, particularly from the perspective of the individual seeking support, is incorporated into stuttering therapy.

What does this mean for people seeking therapy?

Our research highlights the importance of defining and describing your goals and preferences if seeking therapy. It suggests that how you feel about your therapist and the content of your therapy really matters. It is important for you and your therapist to understand your goals, so that you can identify appropriate approaches or activities. If something does not feel ‘right’ or relevant for you, speak out.

What does this mean for SLPs?

Our research highlights the importance of open discussion around not only the person’s goals for therapy, but also the tasks or activities to be incorporated in that therapy. It further suggests that incorporating evaluations of the working alliance at an early stage in the therapeutic process may help ensure that relevant goals have been identified and agreed and that meaningful tasks are in place. Such evaluations can also help therapists and persons who stutter to more easily identify, acknowledge and repair challenges should they arise. Tools for evaluating the working alliance are available. One such example is the Working Alliance Inventory – Short Revised version (WAI-SR) (Hatcher & Gillaspy, 2006). This tool was used in the Sønsterud et al. (2019) study referred to above. It is quick and easy to use, and explores the working alliance across the three domains of bond, goal and task.

If you would like to find out more, the WAI-SR is available online and the Sønsterud, Kirmess, Howells, Ward, Billaud Feragen & Halvorsen (2019) paper is available on this link.  We believe more research is required to further investigate the role of shared understanding of therapy goals, agreement of relevant therapy tasks, and a respectful and trustful bond in stuttering therapy.

References

Bordin, E. S. (1979). The generalizability of the psychoanalytic concept of the working alliance. Psychotherapy: Theory, Research and Practice, 16(3), 252-260.

Flückiger, C., Del Re, A. C., Wampold, B. E., & Horvath, A. O. (2018). The Alliance in Adult Psychotherapy: A Meta-Analytic Synthesis. Psychotherapy, 55(4), 316-340. doi:10.1037/pst0000172

Hatcher, R. L., & Gillaspy, J. A. (2006). Development and validation of a revised short version of the Working Alliance Inventory. Psychotherapy Research, 16(1), 12-25. doi:10.1080/10503300500352500

Horvath, A., Del Re, A. C., Fluckiger, C., & Symonds, D. (2011). Alliance in individual psychotherapy. Psychotherapy, 48(1), 9-16. doi:10.1037/a0022186

Manning, W. H. (2010). Evidence of clinically significant change: the therapeutic alliance and the possibilities of outcomes-informed care. Seminar Speech and Language, 31(4), 207-216. doi:10.1055/s-0030-1265754

Plexico, L., Manning, W. H., & Dilollo, A. (2005). A phenomenological understanding of successful stuttering management. Journal of Fluency Disorders, 30(1), 1-22. doi:10.1016/j.jfludis.2004.12.001

Plexico, L., Manning, W. H., & Dilollo, A. (2010). Client perceptions of effective and ineffective therapeutic alliances during treatment for stuttering. Journal of Fluency Disorders, 35(4), 333-354. doi:10.1016/j.jfludis.2010.07.001

Sønsterud, H., Kirmess, M., Howells, K., Ward, D., Feragen, K. B., & Halvorsen, M. S. (2019). The working alliance in stuttering treatment: A neglected variable? . International journal of language & communication disorders, 54(4), 606-619. doi:https://onlinelibrary.wiley.com/doi/10.1111/1460-6984.12465

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Comments

Growing together: The importance of the therapeutic relationship in stuttering therapy – Hilda Sønsterud and Kirsten Howells — 70 Comments

  1. This was a great read. I couldn’t agree more, it’s VERY important for the client and clinician to connect on an emotional level. Without that, the client doesn’t put as much trust in the clinician, and therefore the therapy isn’t as effective as it could be. Thanks for writing this!

    • Dear Ariel!
      Wonderful to hear from you! We really appreciate your willingness to link our article to your blog. We appreciate your comment about the working alliance and the importance of being connected on an emotional level. Your blog looks great, and we think more people should follow your way of living – by being yourself!

  2. By the way, I’m linking this article in my stuttering blog! AArielRenee.com 🙂

  3. Hi Hilda and Kirsten

    Thanks so much for this paper, and for sharing your research. I am encouraged to see more and more SLPs promoting the “working alliance in stuttering treatment”, and I am sure that your influence will benefit both the SLPs and PWS.

    I am encouraged, too, to read about the alliance combining technical aspects, such as treatment goals, and emotional aspects, such as the nature of the relationship between the therapist and the client. It seems that you are guiding us to a place where counseling is part and parcel of the treatment, and this, to me, is so very important.

    Thank you.
    Hanan

    • Hi Hanan,

      Thank you so much for your thoughts and kind comments. The results of this project were very interesting and I found it fascinating to consider the practical elements that contribute to that emotional bond between two people working together.

      We do really hope that these findings will encourage PWS and SLPs to be able to look at their working relationship and regard it as a key component in any therapeutic process.

      Many thanks once again,
      Kirsten

  4. Hello Hilda and Kirsten,

    I am so pleased to see your paper on the therapeutic alliance in this year’s conference. Over the years, as a PWS, school SLP and consultant to school SLPs in stuttering, I have come to regard relationship as the central principle of stuttering therapy, around which all other principles orbit. I am thinking of what Kristin Chmela says about relationship: Helping a child who stutters starts with a conversation; that conversation shows interest in what the child is interested in, and it creates relationship. A positive relationships fosters the motivation required for a child with persistent stuttering to choose to continue to evolve as a communicator. As you write, “relationship matters”! Best,

    Rob Dellinger

    • Hi Rob.

      Thank you so much for your interest in our article and for your comments. Our research focused on adults, but it would be of enormous interest to understand which elements contribute to the forging of the working alliance between children who stammer and SLPs. As you and Kristin say, the relationship develops through genuine conversation, and it would be of enormous value to understand more about what makes some therapeutic relationships more successful than others.

      Many thanks once again,
      Kirsten

  5. Hello Hilda and Kirsten,

    Thank you so much for sharing this article. I am a graduate student currently enrolled in a Stuttering evaluation and therapy course! After my group mates and I read and discussed your paper, we wondered how often you would suggest incorporating/administering the WAI-SR to assess the working alliance?

    Best,
    Cayla, Jayna, and Blair

    • Dear Cayla, Jayna and Blair,

      Thank you so much for your interest in our article. We’re so glad that it has stimulated discussion amongst you and your group mates!

      Our study followed a strict schedule of meetings between the SLP and the PWS seeking therapy, which included an initial meeting, followed by four treatment sessions, and a subsequent follow-up. This protocol is unlikely to reflect real-life clinical situations within many environments. However, within our research protocol, the WAI-SR was administered at the second and fourth treatment sessions, and at the one-month follow-up. When used in real-life clinical situations, it is likely that incorporating the WAI-SR fairly early in therapy is likely to optimise the opportunity for the SLP and the person seeking therapy to actively use and discuss the findings, amending their collaborative therapy approach accordingly. This is reflected in our use of it at the second treatment session (which was the third time the SLP and PWS had met). A generally useful guideline might be early in the therapy process, when therapy is underway, but not so far along that it is difficult to change course.

      I hope my musings are useful!

      With warmest wishes,
      Kirsten

  6. I enjoyed reading this article and appreciate the emphasis on the working alliance. I like how it encompasses the three important components that can influence a client’s performance in therapy. It’s not a term I hear very often but it allowed me to reflect on how I’ve been addressing these topics with my clients. I look forward to using the WAI-SR in the future and incorporating it in stuttering therapy specifically. I frequently have discussions regarding goals and tasks but not much about the “bond” aspect. Considering the importance of the bond between the client and therapist in stuttering therapy, how would you suggest addressing negative ratings/responses to “bond” questions?

    Thank you,
    Gabriela

    • Dear Gabriela!
      Thank you som much for your interest, and for sharing some of your reflections about the working alliance. I am happy to hear that you consider to include the WAI-SR instrument in your clinical work in the future. I will continue doing the same. If we choose to include this form, I assume that it is easier and more natural to include aspects related to the process bond in our conversations with PWS. According to Wampold, the bond is the basis of the collaborative relationship, and needs to be created initially in the therapy process. If we as clinicians dare to discuss more openly the quality of the dyad, we might better be able to identify and agree upon goals and meaningful tasks as well -which again might contribute positively to the therapy outcome. Therefore, I would address the ratings to bond questions seriously too, in particular the items about respect and care. I have received two comments from PWS throughout the last four years related to the bond items (‘likes me’ and ‘appreciate me’) that they considered these aspects not so important. One person mentioned that the aspect of ‘liking me’ is not so important in professional relationships as it is in private relationships. Anyhow, by including it in your work, you, together with your PWS, will experience yourselves how the form works for you.
      All the best wishes, and thank you again from
      Hilda

  7. Hilda & Kirsten,

    Thank you so much for sharing this highlight and a link to the full paper. I agree, the therapeutic alliance is an integral part of the therapeutic process.

    This topic of a “therapy alliance” was first introduced to me in the Plexico, Manning, & Dilollo 2010 paper. Thank you for further discussing and clarifying points from both the client and clinician’s perspective.

    I recognize that the alliance is important, and working together with the client on both goals and therapy approaches. How would you recommend building that alliance when the only goal the client wants is complete fluency and doesn’t see value in overcoming self-stigma, etc?

    Thank you,
    Erma Hanson

    • Dear Erma!
      Thank you for your feedback and for showing interest in the topic!

      You add a very important question which is very relevant, and which is a quite common topic in stuttering therapy. I am sorry that my answer below will be just a small piece of an answer.

      Regardless of the content in the goal-led therapy, I think that we as clinicians should consider all goals from PWS very seriously/carefully and with genuine respect. I do assume that we as clinicians experience individual therapy goals expressed like for example ‘I want to get rid of the stuttering’ or ‘I want to be complete fluent’ from time to time. In these contexts we do have to listen just as carefully as usual. In such cases, I as the SLP can probe further by asking for example what would happen or what would be different for them if they achieved this specific goal. If we are wondering why being fluent matters to them, we usually receive further important information about reasons which are understandable about why the person is expressing such goals. Often there are issues which might be related to coping in life in more general. Maybe the specific reason is to read bedtime stories for their children, starting a meaningful education/job which demands increased control in speech, or being more active in social situations etc.. Then the initial goals could be regarded as process goals, and the additional information more could be regarded as outcome goals. When I do reflect together with the person about these issues, I do experience that something might change already early in the collaborative process. Often I recognize that the goals might change throughout a few therapy sessions. Some might find the goals of for example making speech or communication less effortful or increasing the sense of control in life as good alternative goals. Then the persons might more easily accept that they stutter, and they also become more open and curious about their own stuttering. Then the working alliance might be even stronger -at least when the person experiences that he/she doesn’t need to struggle that much.

      Furthermore and in general, I am careful about telling that a goal is totally unrealistic, because I don’t know this for sure. Of course, I can inform the person about that achieving total fluency is more seldom, especially when adults with chronic stuttering are concerned, but in the same time I do not want to take away someone’s hope. Usually people are much more motivated and function more effectively when the activities/tasks are aligned with goals that the person hope to reach.

      Well, I do hope that these lines make sense for you.

      Thank you again, and best wishes from
      Hilda

  8. Hilda and Kirsten-

    As a graduate student in speech-language pathology, my relationships with the people I am working with are so important, but it can be hard to effectively analyze that relationship and what exactly is leading to it being successful or not. I appreciate your link to the WAI-SR. I will be incorporating this into my toolbox for future practice.

    The therapeutic alliance integral to a successful outcome. How do you address it when the client and therapist do not have the same goals in mind and are not on the same page? Are there ways to strengthen that alliance or are there times when it is best to end the therapeutic relationship?

    Thank you,
    Megan Izzo

    • Dear Megan Izzo!

      Thank you for your interest in our article, and for sharing a common challenge upon what to do when there are lack of joint therapy goals!

      Goal-directed therapy usually requires a high level of clinical competence and also integrating therapy procedures very flexible. If you and your client are ‘not on the same page’ or you have different goals in mind, I think it might be important to share this information as early as possible. Anyhow, I would listen very carefully to the client before I am disclosing my own clinical goals, especially if or when they are not mirroring the wishes or goals of the person.

      I have been sharing a response to Erma Hanson just recently (please see above). I assume that this feedback might fit quite well with your clinical concerns. Of course I do think that there sometimes might be a discrepancy between desired and realistic outcomes. Anyhow, I assume that if you and your client does not find a common collaborative ‘page’ after an honest and good talk or after a few sessions, it might be very hard (for both of you) to continue the collaborative work. In the same time, authentic and honest shared reflections from both the perspectives usually increase the quality of the working alliance. I therefore sometimes invite the person to agree upon some goals by breaking them down into sub-goals or tasks. Usually it is easier to find a joint platform or ‘page’ for further collaboration then.

      Thank you again for your feedback and important question. I wish you the best for your important work within the stuttering (and cluttering?) field in the future!

      Best wishes,
      Hilda

  9. Good Morning Hilda and Kirsten,

    I want to extend my thanks for having such a concise, informative paper regarding the importance of a therapeutic alliance. Personally, I believe a therapeutic alliance can apply to all clients, not just clients who stutter. I enjoyed that there is so much research to support the importance of therapeutic alliances between the clinician and a client who stutters. Using evidence-based practice is such a crucial thing for clinicians to be able to provide the best possible services. I appreciated all the additional resources I was not yet exposed to. I had never heard of the WAI-SR and providing the link made it easy for me to save for later application.

    Additionally, I had never heard of the identification of the bond, the task, and the goal. I really like the idea that those 3 variables are vital in being a successful clinician. I particularly wonder about “the task” because psuedostuttering can have such a vital impact that it is an important task that should be implemented. However, I worry that clients may be against that task because of the uncomfortableness that it will bring. If a client refuses to participate in that particular task, would you continue to ask your client if they are ready for that task yet as therapy progresses or just accept their decision and not bring it up again?

    Thank you!
    Mackenzie McBride

    • Dear Mackenzie,

      Thank you so much for your message. We’re really glad you enjoyed reading our paper and found it useful.

      I agree that, when it is relevant to an individual’s therapy goals, pseudostuttering can be an extremely powerful experience and tool. Within my own clinical experience, some individuals do, however, find the prospect of this task too uncomfortable to contemplate, or do not feel this approach will be helpful for them. As a therapist, I can propose activities and tasks and explain why I believe these will be of benefit. Together with the client I can also break down activities into smaller steps, so that each step may be a challenge, but an achievable one. Ultimately, however, the people I work with are the experts on themselves, and I respect and accept their decisions and preferences regarding the components of their therapy. Within a constructive therapeutic collaboration, I feel it is ok to propose this activity again at a later date if I feel it continues to have relevance, and continue that discussion.

      With best wishes,
      Kirsten

  10. Hilda and Kirsten,

    Thank you for all the information, I appreciate that you addressed both sides of the relationship. I have been learning about the therapeutic alliance and understand how it needs to be foundational for any therapy. Although I appreciate the importance of working together on goals and therapy activities, as a professional, what do you do if someone says the only goal they have is to fix their stutter? Knowing that fluency techniques can be used but won’t fix it, what would you do to bridge the gap between their goal and what you know is a realistic goal?

    Thank you,
    Jessica

    • Dear Jessica,

      Thank you so much for reading our paper and sharing your thoughts with us!

      We’ve had a few questions along similar lines, and have been struggling to keep up with replying to everyone! However, since you posted your question, Hilda has posted a couple of comprehensive replies which provide some useful suggestions. Please see Hilda’s replies to Erma and Megan above for more info.

      With very best wishes,
      Kirsten

  11. Hilda and Kirsten,
    As an SLP Graduate student with a client who stutters, I am very interested in this topic. A lot of our text books and other readings have emphasized the importance of the client clinician alliance. Because I only have a few weeks to work with my client, I feel this emphasis, especially. As I endeavor to build this relationship I will be adding in aspects of client evaluation to our sessions in order to help ensure as collaborative an experience as possible.
    Thank you for presenting this.
    Regards,
    Tabitha Syme

    • Hi Tabitha,

      Many thanks for your comment. We hope you found the paper useful, and that the WAI-SR is a tool you may consider using to evaluate the working alliance with your clients.

      With very best wishes,
      Kirsten

  12. Hilda and Kirsten,

    Thank you for sharing this article on working alliance. As a Speech Language Pathologist graduate student, this is a great topic to discuss and learn more about. While working with our clients, it is important to create a relationship in order to allow a safe and open discussion and allow for growth. I found this article educational by learning the importance of an alliance with our client’s as well as their parents. Parents may also feel alone in this situation and it is important to provide community support groups for them too. We tend to focus on our client’s needs and might forget about informing services for the parents.

    Thank you,
    Rebecca

    • Dear Rebecca,

      Many thanks for reading our article and sharing your thoughts with us. Although our study explored the working alliance between the SLP and adults who stutter, I agree with you wholeheartedly that the parents of children who stutter may often benefit from direct support themselves.

      With best wishes,
      Kirsten

  13. Hello Hilda and Kirsten,

    Thank you for sharing your insight. As a future SLP, I hope to always try my hardest to make future clients feel secure, safe, and able to express themselves in my presence. I was wondering, while given all the perfect circumstances, a good/safe environment for conducting therapy, and excellent client-patient relationship, etc., do you think it is possible to see little to no success in this particular subject? Would the younger children be more susceptible to seeing quicker results since they are still molding their language versus adults?

    Thanks,
    Casey

    • Dear Casey!
      Thank you so much for your feedback and for showing interest in the topic! I think that the subject descriptions presented above will make a very good starting point. What we do invest in the client-clinician relationship is of high importance, and within the working-alliance common shared goals and tasks are also included, in addition to the quality of the bond. Regarding your last question about children being more susceptible to seeing quicker results, I believe that this issue is related more to personal differences rather than age differences.
      With best wishes,
      Hilda

  14. Hi Hilda and Kirsten,

    I am a current graduate SLP student and doing my externship at a middle school. I am working with a student who stutters at the moment and have administer the SSI-4. You mentioned that there are tools to evaluate the relationship between the therapist and student. My question is: would you recommend this evaluation to be provided after rapport has been built, or only when a problem arises with the client? Also, this student has a tendency of not attending class and sometimes missing therapy sessions due to this (she is not in scheduled class when we go pick her up). Therefore, there is a lot of counseling going on during our sessions (when we do meet). Do you recommend the Working Alliance Inventory – Short Revised version (WAI-SR) (Hatcher & Gillaspy, 2006) to be administered with this client?

    • Hi!
      Thank you for showing interest in the topic!
      I don’t know much about your client (student), neither the age. Therefore it is hard to recommend anything based on your information. In general, we advice to wait until minimum the third treatment session (if we intend to use the WAI-SR), because the person has to build his/her considerations on something. In general, and regardless of age, it is important to ask the person himself what matters or is important, and what the person find helpful. This is basic, but necessary to remember and to do regularly.
      Best wishes,
      Hilda

  15. Hi Hilda and Kirsten,
    Thank you for your research and explanations of a strong working alliance between a speech pathologist and an individual who stutters. I liked how it was explained simply by evaluating the bond between the clinician and the client, agreement on the goals of therapy, and the tasks to reach that goal. As a speech pathologist graduate student, I feel that it would be a quick helpful task to regularly check in on bond, goal, and task with the client to be sure you are in agreement and moving in a positive direction throughout treatment. The WAI-SR is also a helpful resource; thank you! I also appreciated how you mentioned that individuals seeking treatment should shop around. We all have different personalities and styles, and in something as vulnerable as stuttering therapy, a right fit is important. I also appreciated your advice to individuals to “speak out” if there are any questions about treatment tasks or goals, as the open communication is imperative for building a positive relationship. Thank you for your presentation!
    Nicole

    • Dear Nicole!
      Thank you so much for your interest in our article. We’re so glad that you find the information helpful!

      I totally agree with you that a right fit is important. Furthermore, it is so important to ask regularly if what we do in therapy is considered helpful. Hopefully what we do together with the person is in accordance with what the person himself find meaningful and important. It is fundamental, and you describe this aspect so perfectly well.

      Regarding the choices of words; it is the StutterTalk which is using the words ‘shop around’. We are aware of that for some (or quite many?) PWS or significant others there are not always easy to find another SLP if the quality of the working alliance is critical or if the alliance seems to be difficult to strengthen or repair. Anyhow, to be open and honest is the best way for building a positive relationship, as you yourself suggest.
      All the best wishes for your important work!

      Best wishes,
      Hilda

  16. Hello Hilda and Kirsten,
    I enjoyed your discussion of the importance of therapeutic alliance. I like the idea of having an evaluation tool to facilitate the ongoing discussion between the clinician and client about their rapport. I thought it was interesting that you pointed out that both therapeutic goals and treatment activities should be agreed upon by both the clinician and the client. The idea of ensuring that all treatment activities need to be something that the client agrees is appropriate made me wonder if that ever leads to a situation in which the client fails to make as efficient progress because they aren’t willing to agree to treatment tasks that are uncomfortable or overly difficult at first. Is that something you have found occurs in this model? How would you recommend a clinician work to avoid this type of problem?
    Thank you,
    Sarah Aldrich

    • Dear Sarah!

      Thank you so much for reading our paper and sharing your thoughts with us.

      I will just give a short and general answer to your important question. If there is a meaningful rationale behind the tasks you find useful or are trying to implement, and you explain to the person this rationale in an understandable, caring and context-sensitive way, then my experience is that most of the decisions regarding tasks for achieving the mutual goals or changes may be positive evaluated by the person.

      With the best wishes,
      Hilda

  17. Hello,

    I really liked your explanation of therapeutic alliance as the bond, the goal, and the task. I think this provides a functional framework for self-evaluation for clinicians who service persons who stutter. I am a graduate student studying speech-language pathology and today I had this exact conversation with my clinical supervisor. We were discussing the importance of incorporating parents goals and understanding their beliefs about therapy for their child. She further explained that when a parent does not feel heard or received by the clinician it can often create that situation in which the parents feel the need to shop around for a new clinician. And while there are times that it is important to shop around for a knowledgeable and fitting clinician, I think as clinicians its important for us to asses how we are assisting this process. Are we balancing our clinical expertise and treatment ideas with the thoughts of the client to provide successful outcomes for that particular individual. Thank you for your paper.

    • Hi!
      Thank you so much for your message. We’re really glad you enjoyed reading our information, and that it was relevant to your talk with your clinical supervisor.

      You are describing a very important issue about keeping a trustful collaboration with parents. I totally agree with you, that feeling heard and seen is the basic feeling in all the collaborative work.

      Unfortunately, for some parents there might not always be so easy to find the best SLP for their children, and who fits well with everything. Anyhow, if they have access to several SLPs, this is usually not a problem. Anyhow, my impression is that most of the SLPs keep a high quality of their work, and to be open and honest (in both/all directions) is the best way for building a positive relationship. The art of balancing well might be the best way for keeping the highest standard, I agree with you in this and all your points.
      Best wishes,
      Hilda

  18. Hello,
    As a future SLP, I understand the importance of a strong working alliance. I have a few questions over the process of the WAU-SR. After your initial evaluation with a patient, you agree you have a strong working alliance and start therapy. If you were to run another WAU-SR evaluation later into the patient’s therapy, and you and the patient find the work alliance no longer lines up what steps would you take from there? Recommend a new therapist? Re-evaluate the goals of treatment? And how often do you need to evaluate the work alliance?
    -Alexis

    • Dear Alexis,

      Thank you for reading our article and for posing such a thoughtful question. If you were to experience the situation you describe, my suggestion would be to open up a discussion about these findings and, discuss together, what steps could be taken. A re-evaluation of the goals or the activities selected to facilitate progress towards those goals are likely to form part of that discussion.

      With best wishes for your future as an SLP!

      Kirsten

  19. Hilda and Kirsten,
    Thank you for speaking about this important topic. I think that the therapeutic alliance is really interesting because as a student clinician the emphasis for most supervisors and professors is the validity of the treatment and not the client-clinician relationship. I also am aware of some of the barriers we have a clinicians because we are not counselors. We can listen and support, but what if there are issues we aren’t prepared to deal with? How do you know your boundaries as a clinician? Do you ever collaborate with a counselor to make sure your client is being supported in the best way possible?

    Thank you,
    Amanda T

    • Dear Amanda,

      Thank you for reading our article. It’s wonderful that you recognise the influence that the therapeutic alliance can have on the experience and outcomes of therapy. As SLPs we certainly use plenty of counselling skills within our every day work, and these may form a large part of certain therapy approaches.However, there are times when it is appropriate to collaborate with or refer a client on to a psychologist or counselor to ensure a client is receiving the support they need.

      Thank you once again for your engagement with this topic!

      Kirsten

  20. Hello Hilda and Kirsten,

    I enjoyed reading your reading your post and it is a great reminder of things I have learned in my graduate fluency disorders class. As a graduate student, I have had the opportunity to work with fluency clients for short periods of time as I complete my clinical practicums. What effect do you think short term clinical practicums have on the therapeutic alliance between clinicians and people who stutter? It seems as though student clinicians may develop a strong therapeutic alliance with their clients throughout a semester, but then the student clinician must leave that placement within a few short months. I imagine that this could be difficult for these clients to know that the alliance they are forming is temporary. What advice would you give to student clinicians that may be facing this challenge?

    Best,

    Annika

    • Dear Annika,

      Thank you for your interest in our article and your thoughtful consideration of aspects of clinical practicums. I feel that short-term clinical practicums can potentially be of enormous benefit to both clients and students as long as all parties are aware of the framework from the outset. Many goals (and therapy approaches) are a good fit for short-term interventions, or a larger goal may be broken down into a series of short-term goals, which can be approached during a short period of intervention. Also, student clinicians are often working with a small number of clients, and clients benefit from the time and thought that students are able to devote to the therapeutic process.

      So my advice to student clinicians would be to face this challenge with optimism, adopting an open and collaborative attitude to working with your client, and making sure your client is aware from the outset of the framework (in terms of time) of your involvement.

      With best wishes,
      Kirsten

  21. I have the sense that you are primarily referring to adults in this paper. I am a graduate student of speech-language pathology and I am participating in a supervised clinical placement in the U.S. public school setting. I definitely feel that the relationship between therapist and client weighs heavily on therapy outcomes. I am wondering about how extensively this bond-goal-task model of working alliance can be applied to a 9 year old boy I am working with in the public school setting. I wholeheartedly agree that the goals and activities of treatment should be meaningful to the client, but I would think this would look a bit different for children, especially when it is less of an elective treatment. Do you have any experiences and/or suggestions to share for this age group relating to your topic?

    • Dear Chanah,

      Thank you for reading our article and sharing your thoughts and question with us. Yes, you are quite correct – our study investigated the working alliance in adults who stammer working with an SLP. A modified version of the Working Alliance Inventory (WAI) for children and adolescents has been investigated in Portugal (see link for more info https://psycnet.apa.org/record/2016-54316-001). However, there are many less formal ways to investigate the aspects of bond, goal and task with school children. These include activities taken from solution-focused therapy approached, which use discussions about the child’s hopes for the future to identify goals, and discussion about what would represent a step towards that goal to identify relevant activities. If you are interested to find out more, the paper on this link can give you some more information about solution-focused approaches when working with children who stutter.

      With best wishes for your current clinical placement!
      Kirsten

  22. Hi Hilda and Kirsten,

    Thank you for sharing your findings in regards to the working alliance between the therapist and the person who stutters – it serves as a great reminder that there are other important elements to successful therapy aside from well-written treatment goals. I am a current speech-language pathology graduate student and will certainly keep these findings in mind as I move into practicing in the field.
    I did have one question about utilizing the WAI-SR with a client who has a parent that would also like to be involved in treatment. For a 15-year-old who stutters with a parent who has suggestions for treatment goals, for example, how much are the parents suggestions taken into consideration? Does this tool strictly include only the therapist and the client, or are outside stakeholders considered?

    • Dear Audrey,

      Many thanks for your thoughtful reading of our paper and for the questions you have posed. Family dynamics in therapy vary considerably from family to family and, particularly so during adolescence. For some 15-year olds, parents may still be directly involved in therapy, whereas others may prefer to walk the therapy journey independently without the direct involvement of their parents. It is important to be clear on who your client is. Parents often benefit from support and it may well be appropriate to target therapy at the parent. If the parent is your client, then goals, tasks and evaluations need to be elicited from them. However, if the 15-year old is your client, then the parents’ views can be invited and welcomed, but it is the client’s views that carry the most weight, as this is the person you are supporting and have a responsibility towards. The WAI-SR can be used flexibly and there is no reason why you cannot use this with parents, alongside relevant evaluations for your client. Note that a modified version of the Working Alliance Inventory (WAI) for children and adolescents has been investigated in Portugal (see link for more info https://psycnet.apa.org/record/2016-54316-001).

      I hope these musings are useful!

      Best wishes,
      Kirsten

  23. Hilda and Kirsten,

    As a graduate student and future SLP I found this article very informative and a great read. Being in my clinical rotations and out in the field I find it very important for all my clients to trust me and feel comfortable. When a client is uncomfortable with me or doesn’t trust me, it sets the whole therapy session off. So I agree when you say there should be a bond between the client and therapist. We were taught in graduate school to always discuss our goals and tasks with the client and care giver before therapy begins and again for every session. Just so our client will know what is going on and will be comfortable. But I find myself not informing a young client (age 3) as much due to comprehensive level. Do you suggest involving the parents or caregivers therapy ideas/goals when using the WAI-SR if the patient is too young?
    Sometimes I feel as if some therapist focus solely on the outcomes of the therapy and the “data” instead of thinking about the working alliance or therapeutic alliance. Part of this I feel is because of our restrictions as therapist and not a counselor or phycologist. In one of my graduate school classes we discussed a research article on speech therapy and counseling. This article discussed the closely related task the two fields inter counter and whether or not SLPs should take some classes for counseling due to being a support system and helping a client get through a difficult time or struggle. Specifically a client who stutters and is going through emotional struggles. How do you feel when it comes to setting boundaries or how would you establish a line between having a good working alliance vs doing work out of our profession (counseling)?

    I plan to share this with my classmates as we all need to keep these findings in mind when working with a client who stutters.

    • Hello to you!
      Thank you for sharing your thoughts and questions with us.
      Like you, I find the trust between the persons involved of high importance, and that there might be very negative consequences if the trust is not established. Even though the WAI-SR can be used very flexibly, I am not sure whether the WAI would be a useful tool in your clinical setting with a child (3 years old) and the parents. I assume there would be other ways of evaluating/considering the treatment and the working-alliance which could fit better. However, there are many less formal ways to investigate the aspects of bond, goal and task. Furthermore, some of the items in the WAI-SR can be used as an inspiration in the talks with the parents and the people involved. My impression is that everybody (SLPs, parents, teachers, PWSs etc.) wants both therapy processes and therapy outcomes to be positive. Anyhow, when children are involved (3-17years), a modified version of the Working Alliance Inventory (WAI) for children and adolescents has been investigated. You can find the link here: https://psycnet.apa.org/record/2016-54316-001

      Regarding your second question; it is nearly impossible to give a good answer regarding relevant approaches because there are so many different clinical scenarios to address. A combined approach is often meaningful to consider, and this aspect will also be evaluated when the working-alliance is concerned.

      It sounds that you have many exciting clinical reflections to share with others. Thank you for considering to share this topic with your classmates.

      With the best wishes,
      Hilda

  24. Hi Hilda and Kirsten,

    Thank you so much for your insight on the therapist/client relationship and its importance to achieve goals centered on the client. I also appreciate the stress of the importance of a healthy working alliance. am a graduate student SLP and I am also wondering about the line between clinician and counselor. A different article on the ISAD conference refers to CBT; at what point are techniques used to treat stuttering and negative framework more in the scope of a psychologist, and how do we walk that line successfully to the benefit of the client?

    • Hi!
      Thank you so much for your interest in this topic! I believe that all aspects related to stuttering is of importance, and often it is very relevant to combine approaches. My experience underline the fact that in most of the clinical settings, people want to focus on both physical and psychological aspects of therapy. Therefore, it is usually useful to combine approaches. In my own clinical practice, I do combine elements from the Acceptance and Commitment therapy with speech therapy. Sometimes I combine CBT-related work with speech therapy, or if necessary, I do collaborate with psychologists or physiotherapists.

      It is a bit difficult to give a concrete answer to your important question. Anyhow, I do believe that we as SLPs are striving to find the best therapy and are combining approaches and elements in a way which best fit each person. If we are not having the competence which is needed, I do hope that we can support the person (or the parents) in finding another therapist.

      Best wishes from
      Hilda

  25. Thank you for this informative research and article. The working alliance between the therapist and the person who stutters is crucial as it lays the foundation for a trusting relationship. As a graduate student, I have learned that there are many other important aspects of therapy than just gaining and recording data that I think many SLP’s forget about. The bond and relationship between the SLP and the person who stutters is so important and affects the course of therapy and its outcomes. The discussion of ‘shopping around’ for a therapist was a great idea as many will just work with the first one they meet. It is important for each person to feel comfortable and confident with their SLP so that they can form that working alliance with trust. After the bond is formed, the two can collaborate and agree on the goals of treatment including the treatment tasks that are beneficial for that goal.

    • Hi!
      Thank you so much for your feedback. I am really glad you find the paper informative!
      I totally agree with you that the quality of the working alliance is crucial. It is the basis of both the therapy process and the therapy outcome. The expression ‘shop around’ is not our expression. We do refer to StutterTalk’s podcast and position in this regard. Anyhow, in the paper we highlight the importance of developing a positive therapeutic relationship when stuttering therapy are concerned.

      Best wishes from
      Hilda

  26. Hi there ladies,

    Thank you for sharing such an important aspect of seeking help with stuttering. I’ve encountered in the past with my pwn short-lived tenure with therapy, and I’ve heard from others, that a therapeutic relationship will not happen unless both parties are clear that both need to be on the same page and work together to drive the goals of therapy.

    When I was in therapy, I did not have such a good relationship, partly because I assumed that the SLP was the expert and should do the work and I was to just passively participate and hope that something would change with my stuttering. My key take away from that experience was that it was ME that needed to know what I wanted from a therapist working with me on stuttering.

    I wrote a paper shortly after my therapy experience for ISAD, called “Things I Learned in Therapy” and I think it’s every bit as relevant today as when I wrote it in 2009, 10 years ago. Wow! Here is the link to that if you are interested:http://www.mnsu.edu/comdis/isad12/papers/mertz122.html

    Thank you both for writing something so critical to the success of therapy.

    Pam

    • Dear Pam!
      We have to thank you for your wonderful message, and for sharing your personal experiences in relation to your own therapy preferences. Thank you for sharing your breakthrough message about the importance of being actively involved in the therapy process, and for sharing some of your informative material! Your 2009-paper is still so relevant, and it seems that your paper mirrors very well the content in our paper. Your insight and lessons are so powerful! I will definitely share your paper with my collaborative partners here in Norway.

      I am happy to know that you are so actively involved in national and international work (both related to education for SLPs and within communities of people who stutter). I am wishing you a meaningful and enjoyable stuttering awareness day!

      With the very best wishes, from

      Hilda

  27. Hilda and Kirsten,

    I appreciate the overall topic of your presentation! I am currently a graduate student in speech-language pathology and I am learning the importance of having a strong foundation between the SLP and the patient and/or client receiving services. I agree that the connection must also be based on collaborative, purposeful work. In our current fluency course, our professor often mentions that as therapists, we must be able to do everything that we expect our patient and/or clients to do. For instance, we must have a deeper understanding of the emotional and psychosocial aspects that accompany stuttering, in addition to the symptoms and behaviors that we see as the observer. As with any form of therapy, I agree that it is very important to explicitly state the expectations on both sides of therapy. The motivation of the patient and/or client is equally as important as the objectives the therapist proposes. Thank you for your informative post!

    • Dear Chana!
      Thank you so much for your thoughts and kind comments. I agree with you that all aspects related to stuttering is of importance, including emotional and psychosocial aspects. Our research support your reflections on motivation too.
      With the best wishes, from
      Hilda

  28. Hilda and Kirsten-

    Thank you for sharing your findings and insight on the importance of therapist/client relationships and it’s impact on successful stuttering intervention. As a SLP graduate student, I feel it is critical to establish good rapport with clients in all areas of intervention. I agree that it is especially critical when working with individuals who stutter. I thought your statement about shopping around for a therapist who you feel comfortable with was very interesting. I feel that this is especially true for adults who stutter. I look forward to furthering my research on the Working Alliance Inventory and implementing it as I advance in this field.

    • Hi!
      Thank you so much for your interest in this topic and for your reflections and comments. I totally agree with you that establishing a good rapport with people who stutter in all areas of intervention is crucial. The expression ‘shop around’ is not our expression. We do refer to StutterTalk’s podcast and position in this regard. Anyhow, in the paper we highlight the importance of developing a positive therapeutic relationship. Based on findings in our study, the content of our therapy really matters. Therefore, if something does not feel ‘right’ or relevant, it is important to keep the dialogue open and honest in all phases of therapy. As you mention, this is especially true for adults who stutter, but this aspect might be of importance for children and relevant persons involved in the collaboration too.

      Best wishes from
      Hilda

  29. Thank you for your article. I feel that it is important for PWS and the SLP to have a bond. I feel that with that bond the PWS has a better chance of learning the strategies. Both the PWS and the SLP must be on the same page to be able to learn/teach. As an SLP in the schools, I tell my students their goals every time they come to speech. Once again, thanks for you post.

  30. Hi Hilda and Kirsten,
    As a future Speech-Language Pathologist, I really enjoyed reading your paper on such an important area of therapy! (Arguably the MOST important!) I have a question that I hope you will be available to answer. Do you think that in general, a therapist that is kind and very relational, while not exceptionally intelligent, will be more effective with treatment than an exceptionally bright therapist that has a hard time relating to their patients? I’m curious about your thoughts, and I look forward to a reply if possible!

    Best wishes,
    Nathan

    • Hi Nathan!

      Thank you so much for your feedback and your interest in this topic!
      I had to smile when I read your question. What you include in the expression ‘not exceptionally intelligent’ is almost impossible for me to know. In general I believe that relational skills are also related to human intelligence. Furthermore, I do think that the answer to your question is very much depended on the person who is searching for support. Unfortunately, it is very hard for me to give a more concrete and good answer. I am therefore tempted to encourage you to forward your question to another setting or to other people who might be available and willing to reflect further upon your question. Hopefully we can assume that all professionals in our field are both kind and intelligent! 🙂
      Best wishes from
      Hilda

  31. I believe it is very important to not only establish rapport, but also, build a bond when treating a PWS. As a graduate SLP student, I realize that SLPs are stakeholders in providing quality treatments for PWS. These clients have to share their personal and professional experiences, which can difficult to revisit. Therefore, there needs to be a level of trust, confidentiality, and respect between the SLP and the client. Being free to have an open dialogue and actively developing goals and treatment strategies between the SLP and PWS can promote a more successful outcome from the treatment. Thank for writing and sharing this article.

    Wendy

    • Dear Wendy!
      Many thanks for your interest in our paper and your important reflections! I do agree with you in all aspects. Being free to honestly and openly consider the quality of the bond in the therapy dyad, and continuously evaluate the goals and the activities selected to facilitate progress towards those goals are likely to form all parts of therapy.

      Best wishes,
      Hilda

  32. Hey Hilda and Kristen,
    I enjoyed reading this article, and the statement, “let yourself shop around” truly resonated with me. As a 2nd year graduate student, I strongly believe that as a clinician it is vital to develop a rapport with your clients. It is also necessary for the SLPs to understand that the core to our profession is interpersonal relationships. This article as it relates to stuttering was quite enlightening, and makes me more curious about working alliance, and how I can apply it as a future speech-language pathologist. Thanks for sharing!

    Lana

  33. Dear Lana!
    Thank you so much for your kind comments and for sharing some of your reflections with us! We are happy that the topic about the working-alliance is of interest, and we do hope that you will find ways to apply and integrate these aspects into your future clinical work.

    With the best wishes, from
    Hilda

  34. Hello Hilda and Kristen,

    Thank you for this insightful article. I believe that the emotional bond is crucial when working with clients because without this foundation, it will be very difficult to accomplish creating the goals and tasks for therapy sessions. I think it is crucial to take time to think “meta” of the role of the SLP in regards to the role in other’s lives and the mutual relationship one shares with their client. I am currently a graduate student in a fluency clinic and I have enjoyed using this reflection to analyze my own relationships with my clients. I have read some of the previous comments addressing difficulties in creating goals, however, how do you address a conversation when the SLP believes that the client may not need therapy anymore, or when the “final goal” is completed? For example, if an SLP has a client that is used to being in therapy, accepts their stuttering and it’s variability, and the SLP has provided all of the strategies to be applied, how does one address this conversation? Thank you so much for your help in advance.

    Best,

    Ursyla

  35. Hi Hilda and Kristen,
    I come to your paper late in the month, but I am so glad that I waited because I could read all the wonderful comments you added to each inquiry. Your diligent, comprehensive responses were as insightful to me as the paper–which I loved!

    I have been working with children and adults who stutter for over 40 years so I have been able to watch our profession evolve to become a more compassionate, individualized approach that is holistic and places the client’s values first. It has been wonderful to watch this evolution and your paper/comments really take us to the next level. I am printing out your survey for all my clients this week. I am curious (and maybe a little weary) of what my children will say. But! It will be good for me to know.

    I am the chair of the American Board of Fluency Disorders, which helps SLPs obtain specialty certification in stuttering and other fluency disorders treatment. I think that your survey should be part of their clinical protocols. Thanks for sharing it!
    Rita