CONFERENCE CALLS

Conference calls:
THE COMMUNICATION SKILLS APPROACH TO THE MANAGEMENT OF STAMMERING IN ADOLESCENCE WAS HELD ON 14-16 JUNE, 2005 AT STRACATHRO HOSPITAL BY BRECHIN, FACILITATED BY JANE FRY. THE DAYS WERE ENTIRELY FUNDED BY THE GANNOCHY TRUST.

Stammering in
1. Learning from history
Jane referred to the variety of approaches that we can draw on when working with people who stammer. We have a legacy of ideas and strategies, which is vital considering the varied nature of stammering and the individual nature of therapy. Speak more fluently, stutter more fluently and communication skills approaches are commonly integrated, and often applied within the broader context of psychological therapies such as Personal Construct Psychology and, more recently, Solution Focused Brief Therapy and Cognitive Therapy. Importantly, therapy in the UK is typically clientcentred, with therapists responding to the individual goals, needs and preferences of each client. ple stammer, constructing a personal iceberg of stammering (Sheehan, 2001), watching videos of stammering and ultimately observing themselves on video, and by instructing therapists how to stammer as they do. Other techniques include freezing, or holding on to the moment of stammering until physiological tension reduces, and using voluntary or deliberate stammering. By helping clients to acknowledge and confront their stammer, their objectivity and emotional distance from stammering is increased. Clients are then able to be less reactive to moments of stammering, which in turns enables them to manage these moments more calmly and with greater choice.

In June speech and language therapists from all over Scotland, including editor Avril Nicoll, gathered to hear Jane Fry speak about the Michael Palin Centre for Stammerings approach to working with teenagers. Here, Avril and Jane summarise the key themes from a workshop that showed how to integrate fluency management, communication skills therapy and cognitive reframing with young adults who stammer, and particularly highlighted the value of group work.

2. Acknowledging readiness
Jane emphasised the importance of clients being ready for therapy and being able to take responsibility for change. This is particularly the case when working with young adults, who may or may not see their stammer as a priority. As therapists our role is to offer choices about therapy and to support young adult clients in the decisions that they make, which at times may include not attending therapy. Where teenage clients express low interest in therapy we have the opportunity to validate their own decision-making as well as to provide an open door back into our services when the time is right for them. Another aspect of timing in therapy for stammering is related to the pace at which therapy moves. As therapists it is vital that we are aware of the issues that may be involved in change for clients, whether this is related to changing speech or making changes in more general communication style and interaction. Group therapy, particularly for teenagers, can be highly effective as there is both the opportunity to learn from each other and to support each other. Follow-up however is crucial to help clients maintain the changes that they make.

4. Focusing on solutions
Solution Focused Brief Therapy highlights the individuals strengths and builds on what they already do that helps them. By judicious use of language (see feature on p.18) therapists help clients to notice and explore positive changes. Clients are able to tell their story about their problem but are also helped to move towards a future when the problem is less of a concern or issue. Rating scales are used to help individuals identify where they are currently, where they would ideally like to be, and where will be an acceptable goal. This process helps to introduce the importance of establishing realistic goals with young adults who stutter. Specific signs of change are then elicited which typically focus on positive changes in communication, interaction and engaging-in-life activities as well as being focused on fluency. For example, clients may identify that when things are better they will be more fluent, and also that at this time they will be talking more, smiling more, going out more or phoning up their friends more. Avril found it instructional to see video samples of young people who stammer and are attending the Michael Palin Centre, and says their level of coping and emotional literacy is testament to the effectiveness of the therapy they are receiving. Brief therapy is very different to a traditional approach to therapy where our starting place is the clients problem. Avril notes that, when her breakaway group was given a case example of a young woman, it wasnt particularly easy to focus on the womans strengths rather than the problem. (As a colleague commented wryly, The problem is, were all Mrs Fix-its!) A good start is trying the method out on yourself.

JANE FRY IS A SPECIALIST SPEECH AND LANGUAGE THERAPIST AT THE MICHAEL PALIN CENTRE FOR STAMMERING CHILDREN IN LONDON. SHE IS ALSO QUALIFIED AS A COGNITIVE THERAPIST. THE MICHAEL PALIN CENTRE FOR STAMMERING CHILDREN ACCEPTS TERTIARY REFERRALS FOR CHILDREN UP TO 18 YEARS OF AGE AND PROVIDES SUPPORT TO THERAPISTS ACROSS THE UK. THE CENTRE RUNS AN ANNUAL 2-WEEK INTENSIVE THERAPY COURSE FOR YOUNG ADULTS AGED 16-19. FOR INFORMATION ABOUT HOW TO REFER CLIENTS TO THE CENTRE, OR ABOUT HOW TO ATTEND FUTURE WORKSHOPS, SEE WWW.STAMMERINGCENTRE.ORG OR PHONE 0207 530 4238.

3. Creating distance / desensitisation

The workshop included discussion on the importance of helping clients to become more desensitised to their stammer, and the range of activities that help with this process. Clients may be helped to identify and acknowledge both overt and covert aspects of their stammer by participating in group discussions about what happens when peo-

10

SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 2005

CONFERENCE CALLS
ADVERTISEMENT

young adults
5. Reframing self-talk
Jane introduced some key ideas which are central to Cognitive Therapy, another of the psychological therapies used at the Michael Palin Centre. Cognitive therapy is used to help people with a variety of emotional problems, and more recently it has been applied to stammering. In Cognitive Therapy there is emphasis on the role of negative automatic thoughts and negative self-talk in affecting individuals emotional, physiological and behavioural responses to events. A central idea to both cognitive therapy and brief therapy is that our responses to problems frequently make things worse rather than better. Therapists ask questions such as What went through your mind at that moment? and If that were to happen, what would be the worst thing about that for you? to help clients identify their thoughts or predictions about stammering. They are encouraged to test out their predictions rather than accept them as fact, to consider alternative possibilities or ways of seeing things, and to develop more effective problem solving skills. Cognitive reframing refers to the process of seeing something from a different perspective and is a core part of all psychological therapies typically used in the treatment of stammering. Many therapists in the UK have completed post-graduate study in Personal Construct Psychology, Cognitive Therapy, Brief Therapy or Narrative Therapy. Further training and ongoing supervision is highly recommended by Jane for therapists who wish to develop their skills in working with the psychological aspects of stammering. group lies in it providing a forum for young adults to encourage each other and provide each other with positive feedback. Jane emphasised the value of group work for young adults and the importance of communicating with teenagers with honesty and openness. While some clients may require individual therapy first for a number of reasons, or may not find the idea of group work appealing, for many it provides an ideal opportunity to share ideas and experiences, to dismantle the isolation which often accompanies stammering, and to explore and develop their own solutions.

7. Moving on
Where stammering is established or chronic any course of therapy is best viewed as a beginning, or as a continuation of work, rather than the end of it. Our teenage clients are helped to develop personal action plans which clarify how they will continue working towards their goals as well as how they will deal with setbacks. Follow-up days are scheduled for the following 12 months after the group and clients have additional individual sessions if they wish. However there is emphasis on clients continuing independently and developing self-help skills rather than being dependent on the therapist. Our role is thus to provide a map of the territory and to help clients explore for themselves how they might manage their stammer more successfully, have more options related to fluency, and develop their confidence and skill in communicating. Questions that are often used to help clients develop their action plan include: What did you work on that was helpful? Why did you work on that? What are the most important things to keep doing? How will you make sure you keep it going? What is your advice to yourself for the future? What will you do to get back on track when things are not going well?

6. Reducing fear
It is important that as therapists we understand the degree of fear that may be associated with stammering for some clients, and that we are aware of how this fuels avoidance and struggle, as clients attempt to avoid stammering or force through moments of stammering rapidly. As therapists we have a role both in acknowledging and understanding clients fears as well as encouraging clients to expand their comfort zone and reduce avoidance, at the pace that is right for the individual. Clients are helped to gradually approach more challenging situations by working through hierarchies of situations that are meaningful to them, and within these to gradually experiment with managing their fluency differently, thinking about their communication skills and using more balanced or helpful self-talk. At the Michael Palin Centre therapists encourage clients to think in terms of having a go rather than success or failure, and to think about overall communication skills and confidence rather than focus on fluency alone. Again, the power of the

References
Sheehan, J. (2001) Message to a stutterer. Available at: http://www.stutterssc.org/joemessage.htm (Accessed: 17 July 2005).

Resources
* The Michael Palin Centre for Stammering, see www.stammeringcentre.org. * National Special Interest Group Disorders of Fluency, see www.fluencysig.org.uk * For further information on Cognitive Therapy, Jane recommends Beck, J.S. (1995) Cognitive Therapy: Basics and Beyond. NY: Guilford Press. * Introductory information about Narrative Therapy is at www.narrativeapproaches.com, Personal Construct Psychology at http://www.repgrid.com/pcp/ and Solution Focused Brief Therapy at www.brief-therapy.org (Accessed: 14 August 2005).

SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 2005

11