|About the Author: Rita Thurman has worked in the schools and in clinical settings in Utah, Idaho, Illinois, Montana and North Carolina since 1977. Her private practice in Raleigh, North Carolina and Bozeman, Montana focuses on the evaluation and treatment of children, teens and adults who stutter.She was awarded the Clinical Achievement Award by the NC Speech Language Hearing Association in 2012 and the Speech-Language Pathologist of the Year by the National Stuttering Association in 2015, both for her contributions to diagnosis and treatment for people who stutter.
She is a NSA Adult and TWST Chapter leader, and sponsors an annual Friend’s Workshop in NC. She is the Chair of the Executive Board of the American Board of Fluency and Fluency Disorders.
Hope is a cognitive state, not an emotion (Zebrowski, 2013). The first time I heard those words was during a presentation by Patricia Zebrowski at the ASHA convention. It gave me pause because I had always thought of hope as an emotional reaction, something that was difficult to manipulate. The idea that it was a cognitive state, and therefore a skill we could wield to help children and adults who stutter, was empowering. This concept helped me develop a new perspective on my treatment protocols based around the clinical power of hope.
The term “mental time travel” was first coined by the Canadian psychologist Endel Tulving to refer to our capacity for revisiting the past and imagining the future. Tulving claimed that these two abilities are related and rely on the same cognitive and neural mechanism. In other words, we learn from our past to make predictions and generate hope for the future. Studies on brain imaging (Maquire, Addis, 2000) have located that the area of the brain that controls for this skill: the hippocampus. When it is engaged, we are able to revisit the past and explore the future.
Unfortunately, I have met many children and especially teens/adults who stutter, who have negative memories of speech therapy and Speech-Language Pathologists (SLPs). Much anger, hurt, and disappointment often accompany their perceptions of speech therapy–especially if their past therapy was focused on fluency, wasn’t client driven or dynamic, and/or was led by a clinician unfamiliar with the person’s experience with stuttering (Markel, 2017). Now that effort has been placed on bridging the gap between people who stutter and SLPs, the cognitive and emotional aspects of treatment have moved to the forefront. Chani Markel’s wonderful paper in the 2017 ISAD demonstrates ways to facilitate that partnership.
By using “time travel”—what has been helpful/unhelpful in the past—in order to arrange for the future, there is an opportunity to use this way of thinking to build hope and improve treatment outcomes.
I have used “Time Travel” in my support groups to help teens and adults understand how to manipulate their optimism and hope. We set up time lines (What was going on with your parents when you were born? How was your first day in kindergarten? What was it like to ride a bike for the first time? Etc.) We talk about memories (good and bad,) and make predictions based on values/hope. During one teen meeting, a senior in high school related an experience he had in first grade when he was getting on the school bus and the driver asked him his name. He had a significant block and the bus driver mocked him. The levels of pain and hurt from that day transcend any amount of comforting 12 years later. My favorite comedian, Mike Birbiglia, has a formula: Tragedy + Time = Humor. But for people who stutter, the phrase “too soon” can sometimes last a lifetime.
Hope doesn’t mean that past and future events will always be great or that you will always look at the world as a wonderful place. Hope means that you can develop expectations for good events to occur. It requires a cognitive shift.
Separating Thought from Emotion
I believe that the thoughts we generate affect our ability to cope with situations. Excessive negative thoughts impact our ability to respond rationally. Thoughts occur naturally and are part of our cognitive system. How we manage those thoughts helps us turn direction away from despair and towards hope. The ability to use “Thought Defusion” (Harris, 2008) is a concept utilized in Acceptance Commitment Therapy (ACT). It is the process of manipulating your thoughts and thereby decreasing the negative impact they have on your behavior. In The Happiness Trap, Russ Harris explains ways to “distance your thoughts” in order to understand and manage them. Categorizing thoughts as being “helpful” or “not helpful” allows us to sort through and focus on the thoughts we want to hold dear or the thoughts we want to “sit on” for a while. It requires some flexibility, but it also requires persistence. Being able to shift and persist creates a level of optimism and therefore hope.
Rebel With a Cause
As Speech-Language Pathologists, our therapy for people who stutter has historically focused on the speech motor system. This is a system that is more concrete and easier to evaluate. A treatment program spawned from hope may be radical. Throughout society rebels can be viewed as difficult and disruptive. However, rebels can also be leaders, innovators, activists and teachers. In her book Rebel Talent: Why It Pays to Break the Rules in Work and in Life, Francesca Gino, a professor in the Harvard Business School, talks about how innovation is not always accomplished with expertise but rather curiosity.
As the Chair of the American Board of Fluency and Fluency Disorders, the organization charged with establishing Board Certified Specialists, I’ve seen the importance of this curiosity and rebellion. The best Specialists are lifelong learners. Independent of their level of training or years in the field, they look at each person who walks into your classroom/clinic as though they are meeting a person who stutters for the first time. They are meeting that person, and their experience with stuttering, for the first time.
Be rebellious. I challenge you to stop using words like: “Easy onset, continuous phonation (which is actually physiological impossible), pullouts (do you really want to use this term with teens?), cancellation, etc” These words imply: “To stop stuttering, all you need to do is….” This language minimizes the person’s experience with stuttering, it implies a simple solution to a complex problem. This mind set extinguishes hope.
Focusing on the development of hope and helping clients learn optimism is radical to the type of therapy in which most therapists engage. I will argue that it is crucial in working with children and adults who stutter.
Writing Therapy Goals that Focus on Hope
This is the section that every SLP is waiting for! All that rubbish is great to think about, what do I do in my session on Monday? How do I write an Individualized Education Program (IEP-used in the schools in the US) goal that is measurable? As SLPs we are accountable for measuring progress, so how do we write a measurable goal for hope? Perhaps we could use this simple mnemonic to do just that:
H: Heightened awareness of the stuttering moment.
O: Optimism that you can change behaviors and adapt to change.
P: Progress that the client understands and self-documents.
E: Efficiency in communication.
John (not his real name) will identify and understand moments of stuttering in 8/10 instances across three speaking situations. He will understand the physical, emotional and cognitive components by documenting each.
The importance of identification for purposes of modification, desensitization, education and understanding is crucial. However, most important is how the client will manage this. Ask him/her to write a goal for this.
John will release the tension in a block and move forward to use the intended word in 8/10 trials across 5 speaking situations arranged in a hierarchy.
John will identify three unhelpful thoughts that are barriers to communication and describe ways to distance those thoughts in three speaking situations.
Optimism is bred from success, so set up treatment to make your client/student successful. Move from simple to complex and establish speaking hierarchies that are realistic and encompassing.
Additionally, have the client write two goals of their own that reflect taking on risks, ways to shift and persist, and/or ways to increase hopeful outcomes.
Clients should be the ones documenting progress. They need to develop their goals and chart their own progress across those goals. These goals should not be only fluency driven, because that is fleeting, doesn’t always indicate that they had any impact on the outcome, and are too difficult to track across speaking situations. In short, fluency doesn’t matter.
This is where time travel becomes part of your therapy. Make sure your client is able to observe/learn from past events and learn optimism for future events.
I hear the language “effective communicator” utilized excessively in our field. “Effective” is a value judgement. I prefer the term “efficient.” However, we need to be cautious. A person who stutters may find it most efficient and effective to word switch or manipulate the sentence to create fluency. Avoidance behaviors are like borrowing money from the bank, it only feels good for a little while. Have the discussion of efficiency in the absence of avoidance. Develop goals that that are truly individualized and client driven. Even young children can develop their own efficiency goals. One seven-year old child on my caseload wrote the goal: “I will raise my hand in class and give the answer, when I know it –9/10 times.” She followed this with, “If I stutter—it’s not like I am going to fall into a volcano and die…I will just stutter.”
In her book The Optimism Bias: A Tour of the Total Irrationally Positive Brain Tali Short states: “Hope, whether internally generated or coming from an outside source, enables people to embrace their goals and stay committed to moving toward them. This behavior will eventually take the goal more likely to become a reality.”
When our hopeful predictions turn out to be wrong, we simply learn from our errors and try again. We have a saying in my part of the world when things get tough: “Just put on your big girl panties and go to work…” Or “big boy” as the case may be and know that it is not a perfect world. In fact, Brene Brown once said: “Practice doesn’t make perfect, practice makes you realize you don’t need to be perfect” (Brown, 2010).
Be the source of hope for each child and adult who walks through your door for therapy. Guide them as they learn optimism. And as the old saying goes: “All’s well that ends well; if it is not yet well, then it is not quite the end.”
Bengtsson, S. Lau, H. and Passingham, R. (2009) “Motivation to Do Well Enhances Responses to Errors and Self-Monitoring.” Cerebral Cortex. 19(4):797-804 ·
Brown, B., & OverDrive Inc. (2010). The gifts of imperfection: Let go of who you think you’re supposed to be and embrace who you are. Center City, MN: Hazelden.
Gino, F. (2018) Rebel Talent: Why It Pays to Break the Rules at Work and Life. New York: Dey Street Books
Harris, R. (2008). The Happiness Trap: How to stop struggling and start living. Boston, MA: Trumpeter.
Markel, C. International Stuttering Awareness Day Conference (2017) “A World that Understands Stuttering: Bridging the Gap between SLPs and PWS
Maguire EA1, Gadian DG, Johnsrude IS, Good CD, Ashburner J, Frackowiak RS, Frith CD., (2000)“Navigational-Related Structural Change in the Hippocampi…” Brain growth and the cognitive map. Proc Natl Acad Sci U S A.
Sharot, T., (201) The Optimism Bias: A Tour of the Total Irrationally Positive Brain. New York. Random House.
Tulving, E.,N (2002) “Episodic Memory: From Mind to Brain,” Annual Review of Psychology. Vol. 53:1-25
Zebrowski, P., (2013) “The Role of Resilience in Stuttering Intervention for Children” American Speech and Hearing Association Annual Convention Presentation
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