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.|
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.
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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