About the Authors:
|Loryn McGill, M.S., CCC-SLP is the owner of OC Fluency Center in Costa Mesa, CA providing therapy exclusively for people who stutter and at Chapman University she is an Adjunct Professor and teaches the graduate course in Fluency Disorders. At UC Riverside she is a member of a multidisciplinary team examining the benefits of collaboration and medical interventions for stuttering. She has conducted international research examining the benefits of early identification and its benefits. As West Coast Coordinator for Camp SAY she runs overnight and day camps for children who stutter and is actively involved with FRIENDS, The Stuttering Foundation, and the NSA.|
|Stephanie Rodriguez M.S., CF-SLP received her bachelor’s degree in Communication Disorders at California State University Fullerton. She received her Master’s Degree in Communication Sciences and Disorders from Chapman University. Stephanie has had the opportunity to work with St. Jude Hospital, Intervention Center for Early Childhood and Speech Language Development Center. Stephanie is currently completing her Clinical Fellowship year at El Monte City School District in California.|
|Amanda Bloemhof M.S., CF-SLP received her bachelor’s degree in Communications Sciences and Disorders from Biola University and her Master’s Degree in Communication Sciences and Disorders from Chapman University, where she became interested in fluency therapy. She is currently completing her clinical fellowship at Redwood Elementary and Richland Junior High School in Shafter, California. Amanda is enjoying putting all she has learned about stuttering therapy into practice in her school setting|
In a study conducted by Iverarch, Rape, Wong, and Lowe (2017), 24% of a large sample of school-age children obtaining treatment for stuttering were identified as meeting the criteria for a diagnosis of social anxiety disorder, compared to only 4% of students who did not stutter.
Research states that negative peer attitudes can have damaging effects towards people who stutter (PWS) (Mallick, Kathard, Borhan, Pillay, & Thabane 2018). The research clearly shows that teasing leads to increased anxiety, depression, alienation, long-term negative consequences and in severe cases, suicidal thoughts and actions (Blood, 2012). Clinicians cannot eliminate teasing, but they can empower a child who stutters (CWS) with strategies for independently dealing with bullying. The goal of bullying strategies must be to respond, instead of react. Clinicians should find ways to respond to bullying that support self-esteem and confidence. Therefore, it is necessary for students who stutter to eliminate their social anxiety related to stuttering through the process of self disclosure. To date, a simple, age-appropriate self disclosure resource has not been formatted for clinicians to utilize as a therapy tool.
The focus of this paper is to first highlight therapy approaches and activities that prepare children for self disclosure. Secondly, this paper discusses reasons self disclosure benefits a PWS by neutralizing feelings towards the stutter. This paper will explain why self disclosure via the classroom presentation created is the final step within the hierarchy of stuttering therapy. Finally, this paper will provide speech-language pathologists (SLPs) an appropriate clinical checklist of how to incorporate the self disclosure presentation into their therapeutic goals.
Therapy Approaches To Facilitate Self Acceptance
- Acceptance & Commitment Therapy
According to Beilby, Byrnes, and Yaruss (2012), communication effectiveness is diminished if gains in fluency are achieved through avoidance or use of speaking techniques that are burdensome and unnatural (Beilby et al., 2012). For this reason, acceptance and commitment therapy (ACT) is a key therapy technique when working with students who stutter. The framework of ACT is openness, confidence, acceptance and generalization. ACT challenges students to be surrounded by their unpleasant feelings, but not negatively react to them. This process ultimately leads students’ to desensitization of anxiety-provoking speaking situations. Through ACT, students will learn to accept uncomfortable situations and present a neutral response. Clinicians should construct a hierarchy of feared words, listeners, and situations to implement the stages of ACT. Clinicians will aid students in realizing the impact of their stutter either psychologically, emotionally, motorically, or socially.
- Cognitive Behavioral Therapy
Cognitive Behavioral Therapy (CBT), a form of psychotherapy, is a key therapy approach in the treatment of fluency disorders in children. CBT’s greatest concern is demonstrating how one’s personal thinking affects their daily lives. For example, PWS may feel apprehensive about speaking, which are negative thoughts or predictions about the stuttering moment. In addition to personal negative reactions, evidence from Langevin et al., (2009) showed that a child who stutters may experience social exclusion and negative peer reactions, which leads to social anxiety (as cited in Kelman, & Wheeler, 2015, p.166). As a result, a PWS may manage their apprehensive feelings by deciding not to speak or choosing a safer word (Fry, 2009). CBT helps students develop awareness and enables them to challenge their negative thoughts by utilizing more adaptive coping responses, such as maximizing use of positive self-talk and establishing life-enhancing core beliefs (Kelman & Wheeler, 2015; Fry, 2009).
A therapy activity that can be used in conjunction with CBT is the Wise Brain Activity (Hinderscheit, Bodner, & Schools, n.d.) . In this activity, clinicians teach students to use their “Wise Brain.” Clinicians must clarify if a student is only using one side of their brain (i.e., only the thinking side or only the feeling side), it can be a challenge to make appropriate changes in one’s thoughts or actions. Therefore, it is important to use “Wise Brains” and reflect on both thoughts and feelings.
- Stuttering Modification
The stuttering modification approach aims to strengthen acceptance of one’s stuttering, as well as elicit motoric techniques to minimize tension related to stuttering moments. Stuttering modification treatment targets the speaker’s encounter with core behaviors and tension via desentization and assertiveness training. Along with targeting core behaviors and tension, counseling students is an integral aspect of stuttering modification. The purpose of counseling within stuttering modification is to help those who stutter understand their communication disorder, as well as identify ways to cope through education, problem solving and cognitive strategies. The clinician’s verbal responses during counseling moments can influence a student’s acquisition of skills needed for self disclosure ( Blood, Blood, Mccarthy, Tellis, & Gabel, 2001).
A therapy activity that stems from stuttering modification is the Worry Dial. To complete a Worry Dial, the child will brainstorm methods he or she can use to diminish worries such as, using positive self-talk or taking belly breaths. Gradually moving through a hierarchy allows students to expand the number of speaking situations they experience, minimize discomfort and acknowledge stuttering (Murphy et al., 2007).
- Overcoming Avoidance
Avoidance Reduction Therapy (ART) states that a PWS desires to interact with others, but experiences an urge to hide their stuttering. According to the ART approach, these conflicting emotions cause maladaptive secondary behaviors that interfere with communication, such as eye blinking, leaning forward, using fillers, etc. PWS may feel they cannot partake in certain activities due to their speech. ART does not put an emphasis on fluency, but on improving a person’s ability to successfully communicate.
Clinicians can incorporate ART into their sessions by helping the child identify their stuttering patterns. Clinicians should challenge students to voluntarily stutter. It is key to begin these exposures in the safety of the therapy room and eventually branch out to different “real-life” situations (Leiman, 2014). A specific therapy activity to assist in overcoming avoidance is helping children learn to use pseudostuttering, also known as fake stuttering. As a student’s comfort with pseudostuttering increases, clinicians can set up situations, locations, and tasks where students can practice.
Desensitization therapy helps the student confront their stutter and any negative emotions. Desensitization will increase the student’s ability to tolerate stress and build their self-confidence (Fraser, 2010). Dell (2013) suggests clinicians should proceed at a slow pace to build trust with the child. Successful desensitization can be reached with direct, gradual, and successful confrontation of stuttering. According to the American Speech-Language Hearing Association ([ASHA], 1995), clinicians need to instruct students to practice fluent speech in a series of steps. The first step within the hierarchy is to identify when fluent speech is easiest to achieve. Then, the clinician would move toward situations where fluency is more difficult (ASHA, 1995).
General activities and techniques for desensitization can include clinician modeling of stuttering behaviors, clinician modeling of self-corrections, catching stuttering, purposeful stuttering, and contrasting hard and easy speech (Walton, 2018). Desensitization and self-awareness may be a precursor to self-acceptance and positive self-perception, which is the foundation for a student’s ability to self disclose and self advocate (Reitzes, 2005).
- Self Disclosure
Self disclosure of stuttering is the final step of therapy and the overall purpose of this paper. Self disclosure means a child can discuss stuttering with no adverse feelings. Being open with stuttering helps reduce shame and fear, as well as remove the stigma about stuttering. A clinician should not force a student to self disclose before they are ready. The therapy approaches stated above should be successfully completed before the final step of self disclosure. Clinicians need to identify situations associated with negative feelings, and identify a hierarchy of feared speaking situations to begin the self disclosure process (ASHA, 1995). Self disclosure is tremendously important due to the toxicity of school culture for children who experience teasing, bullying, depression, reduced social and academic experiences and negative peer interactions. According to Blood et al. (2011), 44.4% of children who stuttered reported greater occurrences of bullying than students who did not stutter. It was also found that children who stutter have lower self-esteem and less optimistic life orientation than those who did not stutter (Blood et al., 2011). However, research states that peer attitudes can be addressed within the school context (Mallick et al., 2018).
Self Disclosure Through A Class Presentation
A PowerPoint presentation is the final step and most beneficial activity for the self disclosure process when peers in a school setting are the most feared population. The purpose of this final self disclosure milestone is to provide the student who stutters the power to live without anxiety, fear, and embarrassment. A classroom presentation allows the student the opportunity to tell people they stutter and that it is okay. As stated above, a classroom presentation is one of the final milestones for a student who stutters. A clinician’s attempt to reach this milestone before the student is ready, can be detrimental to the student’s therapeutic process. It is the responsibility of the student to independently determine their readiness for the final step of their self disclosing hierarchy. The crucial question is, “What deems a student ready for self disclosure in front of their entire classroom?” The answer is not the age of the student, how long they have been in therapy, or a coincidental “show and tell” scheduled in the classroom in the upcoming weeks. Due to the extremely sensitive decision a clinician must make, a resource checklist has been created to help assist clinicians in determining if their student is ultimately ready to take on the feat of self disclosing in front of their class.
In order to measure clinically whether someone is ready to disclose they are a PWS via a classroom presentation, standardized and non standardized assessments may be incorporated. The standardized measure most suitable to assess a child’s readiness for self disclosure is the Overall Assessment of the Speaker’s Experiences of Stuttering for School-Aged Children (OASES-S). In regards to informal measures, the clinician should send a caregiver and teacher questionnaire that discusses school-based activities and peer situations the child may avoid at home and in the classroom. The teacher checklists must focus on stuttering performance not the child’s academic performance. Although teacher and parent feedback is important, the ultimate reporter should be the child. The student checklist should highlight their feelings towards their stutter and ask questions related to their daily interactions. For example, the student’s willingness to talk in the classroom or on the telephone, and if he or she is relaxed during these interactions. The student questionnaire should ask if the child is able to stutter freely or if stuttering moments trigger feelings of failure. Finally, the clinician must ask the child if they have accepted being a PWS. The purpose of these clinical measures is to justify acceptance one’s stutter and readiness for self disclosure.
The emotional and cognitive effects of stuttering can cause fear, shame and embarrassment. In addition to negative thoughts and feelings related to stuttering, PWS may experience social rejection. According to (Blood et al., 2001), 59% of children who stutter reported being bullied. If a student who stutters learns to overcome avoidance, negative emotional reactions towards stuttering, and commits to self disclosure through ACT and CBT, he or she will be able to speak freely. A PowerPoint presentation can be used in smaller settings (e.g. in the therapy room with peers, friends, family) first to build up confidence and assist the child in reaching the final step of their fear hierarchy. Due to the critical nature of determining a student’s readiness for self disclosure through a classroom presentation, a readiness scale can aid clinicians in understanding the criteria that deems a student’s preparedness. In conclusion, if the proper hierarchy is followed according to a comprehensive view of stuttering, clinicians can help children reduce negative reactions to stuttering, overcome the adverse impact of the disorder, educate others, identify a supportive team of people and communicate effectively and successfully (Yaruss et al., 2012).
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