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Louise Wright, formerly of the Manchester Metropolitan University, is now specialist speech and language therapist in dysfluency and Sure Start Lescudjack with West Cornwall Primary Care Trust.

stammering in adults
Stammering in adults and The McGuire Programme have received a great deal of publicity recently through Gareth Gates from televisions Pop Idol Although Gareth himself has inspired many young people with communication difficulties it is debatable how much the nature of the media exposure has increased understanding and acceptance of stammering in people with a stammer as well as in the non stammering public Has the message got across that stammering is a multifactorial and complex phenomenon? That there is no known cure? That people have the right to be heard whether or not they stammer? Most importantly do people now appreciate that the management of stammering in adults needs to be holistic and tailored to an individuals needs and wishes and that overcoming a stammer means different things to different people? Three people who understand this more than most share their experiences

Claire McNeil is a specialist speech and language therapist in dysfluency with Swindon Primary Care Trust.

Anne Blight started training as a speech therapist but, feeling there was not enough in-depth work for stammerers, got involved as a volunteer instead. Excited by the potential of diaphragmatic retraining - but disillusioned with the way it was being introduced in the UK - she founded the Starfish Project in 1998 as a non-profit making venture aimed at helping adults and young people recover from stammering.

Read this
if you want to offer therapy tailored to individuals be positive and realistic about prognosis equip clients to manage their own communication

1. Assess overt and covert behaviours, reactions and coping strategies. 2. Adapt to individuals, using a mix of approaches and time-scales. 3. Highlight the strengths and resources clients have within themselves. 4. Shift a clients focus from cure to maintainable progress. 5. Pace the flow of information. 6. Use rating scales as therapy tools and outcome measures. 7. Ensure techniques can be incorporated in real life. 8. Empower clients to manage their own communication over time. 9. Let clients know it is OK to have set-backs and to return for help. 10. Take opportunities to share skills with non-NHS ventures.
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Getting to know you
Stammering therapy is a long term process of change that may impact on many areas of a stammerers life But is your client ready to change? Do they have sufficient support in the workplace and at home? What approach(es) would work best for them? Louise Wright explains her decision making process

have worked with people who stammer (of all ages) for the past 22 years and find it as enjoyable and challenging now as when I first started. I worked for 11 years in the NHS, latterly as a specialist in dysfluency, moving on to teach disorders of fluency at undergraduate and postgraduate levels at the Manchester Metropolitan University. Whilst there I also ran a weekly specialist dysfluency clinic supervising students, and carried out research into employment and family issues for adults who stammer. I have worked with adults who stammer individually, in weekly groups, in the workplace involving managers and colleagues, in intensive groups and also on residential intensive courses involving families and friends. Anne Ayre and I developed The Wright and Ayre Stuttering Self-Rating Profile (WASSP, 2000) as an outcome measure for therapy with adults who stammer as a result of our work with adults in the workplace (Ayre et al, 1998) and I use this as a tool both to plan and evaluate therapy outcomes. My approach to therapy is influenced by a number of over-arching principles. I always work with the clients stammer within the context of him or her as a person. I adapt my approach to suit their personality, lifestyle, impact of their stammer on their life, experience of past therapy and their readiness for change (Prochaska & Di Clemente, 1986). I do this by taking time to get to know them, listening to them and involving them in therapy decisions by explaining possible options, experimenting and evaluating the results. I see stammering therapy as a long-term process of change that may impact on many areas of their lives.

have a stammer with mixed overt and covert components but with some natural fluency I might suggest Van Ripers approach of initial identification, desensitisation and variation leading up to modificaton of the stammer (Van Riper, 1973). I tend to favour Contures simpler version of stammering easily by moving through stammers (Conture, 1990) rather then Van Ripers different types of modification. If the client is very fluent with high levels of anxiety about stammering and frequent avoidance then I would suggest Sheehans avoidance reduction therapy (Sheehan, 1975) with easy introductions to voluntary stammering and sliding. However, if they are stammering very severely our first option may be a fluency technique such as slowed speech that will give them more fluency initially and can later be augmented with easy stammering techniques (Neilson & Andrews, 1993). Whatever path is finally embarked upon I usually find it helpful to begin therapy with a period of identification and understanding of normal speech production.

Mixture
Although I would normally outline these three main therapy options to the client at the end of our first exploratory session, in reality of course most clients require a mixture of these types of therapy, either simultaneously or sequentially as their stammer changes and their therapy needs evolve. WASSP can again be helpful here in monitoring progress, discussing change and planning new phases of therapy with the client. In getting to know the person it may become apparent that they would also benefit from help with wider aspects of communication such as improved social skills, assertiveness training, anxiety management, relaxation, cognitive-behavioural counselling and problem solving. They may benefit from a mix of individual therapy, various types of group therapy and involvement of significant others depending upon their needs and rate of progress. Clients usually attend on a weekly or fortnightly basis interspersed with breaks to consolidate change and take responsibility for their own maintenance and therapy problem solving. Long breaks are appropriate when the client decides that therapy has fulfilled their needs for the present and they always have the option of stepping back into therapy should their needs change. My aim in all therapy is to empower the client to manage their own stammer long-term, by helping them to acquire the understanding, therapy tools and confidence needed to react to their changing needs and circumstances. If those around them at home and at work can also understand their stammer and how they are dealing with it, I believe that the person who stammers is more likely to manage and maintain change and those around them are more likely to feel comfortable and positive about the stammer and therapy.

Exploratory
I begin to understand them and their stammer through an initial semi-structured interview (severity of the stammer permitting) and I may follow this up later with additional exploratory tools such as the S-24 Attitudes to Communication Scale (Andrews & Cutler, 1974), Locus of Control of Behaviour Scale (Craig et al, 1984) and Self-Characterisation (Kelly, 1991). I always aim to address the overt and covert aspects of the clients stammer, their reactions to stammering and their current coping strategies. I use WASSP to explore the following aspects of their stammer and to obtain a baseline self-rating measure from which we can measure change following a block of therapy. WASSP includes: Stammering behaviours including frequency of stammers, amount of physical struggle or tension during stammers, urgency or fast speech rate, associated physical movements made as a reaction to stammering, general level of physical tension, eye contact and any other behaviours which are significant. Negative thoughts about stammering before, during and after stammering. Feelings about stammering such as frustration, embarrassment, fear, anger, helplessness. Avoidance as a coping strategy at the levels of words, situations, talking about stammering with others and admitting their problem to themselves. Disadvantage experienced at home, socially, educationally or at work as a result of their stammer. I will usually ask the client to complete WASSP at the end of the initial interview when they have spent some time reflecting on and discussing aspects of their stammer which they may not have considered for some time, if ever. The client at this point records their aims and expectations of therapy. Use of WASSP also helps me to illustrate which areas therapy will address and where they may expect change to occur. Some clients are surprised that I am not just going to address the mechanics of speech. Others are relieved that I understand the complex multidimensional nature of stammering and will be helping them to address it on many levels. For many it is the first step in understanding their stammer and how therapy is going to work. At the end of the first meeting I will describe possible therapy options that will help them to achieve their aims. If they

References
Ayre A., Wright, L. & Grogan, S. (1998) Therapys Long Term Impact on Attitudes Towards Stuttering in the Work-place. In: Healey, E. & Peters, H. (Eds) 2nd World Congress on fluency Disorders, 18-22 August 1997, San Francisco, 403-406. Nigmegen University Press, Nigmegen. Andrews, G. & Cutler, J. (1974) S-24 Scale. Stuttering Therapy: The Relations Between Changes in Symptom Level and Attitudes. Journal of Speech and Hearing Disorders 39, 312-310. Conture, E. (1990) Stuttering (Second Edition). Prentice Hall, Englewood Cliffs, New Jersey. Craig, A., Franklin, J. & Andrews, G. (1984) A Scale to Measure Locus of Control of Behaviour. British Journal of Medical Psychology 57, 173-180. Kelly, G. (1991) The Psychology of Personal Constructs. Routledge, London. Neilson, M. & Andrews, G. (1993) Intensive Fluency Training of Chronic Stutterers. In: Curlee, R. (Ed) Stuttering and related Disorders of Fluency. Thieme, New York.

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Prochaska, J. & Di Clemente, C. (1986) Towards a Comprehensive Model in Change. In: Miller, W.R. & Heather, N. (Eds) Treating Addictive Behaviours: Processes of Change. Plenum, New York. Sheehan, J. (1975) Conflict Theory and Avoidance Reduction Therapy. In: Stuttering. A Second Symposium. (Ed) Eisenson, J.

Harper and Row, New York. Van Riper, C. (1973) The Treatment of Stuttering. Prentice Hall, Englewood Cliffs, New Jersey. Wright, L. & Ayre, A. (2000) WASSP: The Wright and Ayre Stuttering Self-Rating Profile. Speechmark, Bicester.

n Swindon we have a specialist Fluency Service with four speech and language therapists working part-time. We see all ages and run intensive residential courses for children and teenagers. I have worked in the area of stammering for the past 15 years. During this time ways of thinking and types of therapy have tended to come and go. I feel privileged to work with adults who stammer and have met and learnt from many fascinating and brave individuals. The uncertainties in the causes of stammering and its variability make it a challenging area of work. I use a range of therapy approaches but have been influenced greatly by learning more about Neuro Linguistic Programming (NLP) and brief therapy. I have not given up my old favourites of block modification, breath control and relaxation strategies, but tend to mix the ideas and approaches. The great thing about working in this area is that you can keep asking, how is it going?, how are you finding this approach? and gain instant feedback, something not possible in areas where clients are unable to communicate with us so directly. The influence of NLP is evident in my initial assessment where my priority is to build rapport. My aim is to understand as much as possible about the meaning and the experience that stammering has for the individual, to see it through the clients frame of reference. I aim to get a sense of how the person learns - are they mainly visual, auditory or kinaesthetic in the way they use information? This helps us select the kind of therapy activities that will create changes for the individual. In NLP the therapist is aiming to create the conditions whereby the client may choose to change and find new and interesting ways to carry out these changes (Bailey, 2001). I also take the usual case history, gathering information about the nature of the individuals stammering, both overt and covert features. During this process I look for clues to help understand the meaning all this has for the individual.

the work we will do together - their preferred future. Then, on a scale of 0 - 10, I ask Where are you now?, How will you know when you have moved up just one point on the scale?, What will you notice?, How have you managed to get to where you are now? Clients very rarely put themselves at 0, so they are already some way up the scale. One particular client said he had been feeling very depressed and could not see anything positive in his life. When we worked on the scale I noticed he was able to give lots of details of how he would know when he was moving up. He very clearly had a step by step view of what he would be doing as he moved towards his goal or preferred future. I was then able to highlight these strengths to him. Helping him to see that he was able to plan in detail and have an accurate picture of what he wanted was a great resource for positive change in therapy, and it continued successfully.

Acknowledge feelings
Using brief therapy scales helps to set goals and keep client and therapist forward thinking. Although I do not dwell on past experiences, I do not ignore memories that may block future work. It is important to acknowledge feelings. If there are issues that need addressing, using the NLP strategies to soften the impact of these negative memories helps. While thinking about NLP, it is necessary to put in a word of warning. These strategies are powerful and need to be explored in a trusting and supportive environment. I have become aware of these ideas being used in a group, without appropriate support, and this has a very negative effect on a client. In an appropriate supportive environment I have found this way of working very useful in helping to neutralise past experiences and enabling clients to recognise and hold onto positive experiences. In the process of assessment I also use a general outcome scale to have a broad view of stammering behaviours, feelings and attitudes. Avoidance schedules are also useful and it is helpful to look back on these to gauge success. During therapy I like to use a range of strategies which vary according to an individuals needs. I believe it is important to explore practical ways of dealing with stammering at the same time as working to change feelings and attitudes. Having practical to do tasks in a session can really help, as too much talking about things can be hard for some clients. I very often use practical relaxation, and breath control work is also helpful, enabling clients to start to take control of the situation. I use block modification ideas including voluntary stammering which can be a real breakthrough for some individuals. It is important not to forget some of the older ideas which can be very useful. I am now on a Charity committee with someone I worked with 15 years ago; he still uses soft contacts and found this one of the most helpful strategies. It is important not to forget the need to maintain progress. By using techniques to manage both the covert and overt symptoms of stammering I hope clients become aware that they have the necessary tools to deal with the inevitable set-backs. Therapy goals do not include 100 per cent fluency, and creating a positive attitude leads on to an acceptable level of fluency control. Life events do have an impact and we need to say it is okay to have set-backs and to return for help if needed. Past clients will sometimes call if a reminder is needed. Recently a client I had seen in his teens came back, after 10 years, to run through a work presentation. After two sessions to refresh ideas on managing his stammering he completed his presentation successfully and kindly rang me to let me know how it had gone. Stammering can be a chronic, ongoing disability in adults and

Tipping the scales

What does a stammer mean for an individual? And what inner resources do they have which will guide therapy? Drawing on a range of approaches particularly neuro linguistic programming and brief therapy Claire McNeil asks the questions to bring about change

Pace the flow

Something I have learnt with experience is to try to pace the flow of information. At one time, following the principles of block modification during its phase of identification, much time was spent analysing behaviours and covert symptoms. Whilst this information is necessary, I feel that to do too much of this straight away can be daunting for the individual, and I am sure I have lost some clients in the past through too much analysis, too soon. Trying to get a balance between identifying the problems and looking for solutions early on in therapy is important. It is at this point that the ideas of brief therapy really help. Also known as solution focused brief therapy, it looks at the clients hopes for the future. Rather than trying to understand and fix problems, it works by charting your way forward and seeking the resources needed to embark on the journey. The essence of it is to: work with the person rather than the problem. look for resources rather than deficits. explore possible and preferred futures. explain what is already contributing to those possible futures. treat clients as the experts in all aspects of their lives. (Taken from a Brief Therapy Practice course.) Bearing this in mind, when dealing with the initial assessment I try to take history details so as not just to get a picture of what has gone before, but also to encourage the client to express their preferred future. Looking for the clients strengths and resources is extremely helpful right from the first session. I like to use scales as part of outcome measures. The client is asked to consider what they would like to achieve as a result of

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I hope that, in our work settings, we are able to offer support when it is needed. Different types of therapies may well be appropriate in different phases in a persons life.

Resources
Bailey, R. (2001) NLP Counselling. Speechmark. For information on Solution Focused Brief Therapy, see for example www.brieftherapy.org.uk. I have found that, to many of the hundreds of stammerers that I have worked with, there is an affinity to the house fire allusion and stammering. Stammering, like a fire, is self-perpetuating with situation and word avoidances working as fuel to feed the fire, and many stammerers at times must have felt as out of control as a fire often is. As in the case of a fire, the first and most important action is to get the problem under control and this is achieved in Starfish with diaphragmatic retraining, a technique pioneered by Lionel Logue, notably with the late King George VI. This involves learning to breathe using the intercostal muscles and the costal area of the diaphragm. The key to the technique is timing and learning to breathe, speak and release air as a cycle. Once we have put out the fire we do not want it to start up again and so we train with certain safety net ways of getting out of potential blocks or stress related situations, such as voluntary sliding and block and release. We then start on the most important job of all, and that is rebuilding the house, by such techniques as avoidance reduction therapy and positive attitude development.

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Fighting fire with fire
Anne Blight doesnt waste time looking for a non existent cure for stammering Instead her Starfish project offers small intensive courses and unconditional lifetime support to recovering stammerers seeking effortless speech

manage stammering in adults by initiating change and by empowering the individual, with lifetime support, to manage their own recovery - to become in effect their own speech and language therapist. Because of the multifactorial nature of stammering, every person who stammers does so differently; there may be certain similarities but they are all different, all individuals. Therefore, individuality must be respected and therapy adjusted accordingly for it be effective. For this reason, I always discuss at length everything that is involved with anyone considering a Starfish course as it is essential that no one has any false hopes of a non-existent cure or promises of fluency. It is important to try and answer as many questions as possible before the course so that people can come with an open mind and are prepared. I always make it clear that we make no promises. Our aim is for effortless speech; we do not chase a goal of fluency or eloquence, and believe that seeking such perfection in an imperfect world is an impossible task. As much as each individual stammers differently, so too they will recover differently, at their own pace and in their own time. We use the term recovering stammerer as an acceptance that we are doing something about controlling the stammer. We are not cured and never will be. We are - and no doubt always will be - recovering. There is a pride to recovering stammerers even in saying the phrase. Rather than Im trying to... it states positively I AM a recovering stammerer and signals the change in attitude and avoidance that prevailed when I WAS a stammerer. I strongly believe that it is wrong to take financial or psychological advantage of the misfortune of other people. I do not believe in intensive therapy courses that involve large numbers of students working long hours. Because of the construction of such courses there is no allowance for the individual, and a one size fits all approach has to prevail. Short-term fluency gains are seen from such volume therapy approaches but, since so much emphasis is placed on technique, these gains are rarely maintainable in the real life situation. I also do not believe that the solution to years of confirmed stammering can be that rapid.

Rethinking
Rebuilding will be a long process that will involve much rethinking of the original plans - these were no doubt the plans of a stammerer designed around word, situation and relationship avoidance. To rebuild, the recovering stammerer will need to consider and be prepared to adjust these plans as recovery continues, vitally seeking help and involving friends and family in the process. Essential to this rebuilding programme is support and on Starfish we provide this in various ways: 1. A nationwide phone list of recovering stammerers available day and night every day of the year. We feel that the certain knowledge that there is always available, at the end of a phone, a person who has walked in your shoes is a great strength for recovery, and that you can contact someone at the time that you may be having some problem is vital. 2. Local Starfish support groups meet to practise and discuss recovery in a friendly social atmosphere. 3. Groups of recovering stammerers meet to practise the technique in real life situations such as shopping centres and airports. 4. Anyone can, without fee, come back on any course at any time to refresh. There is no pressure or dependence on this refreshing; it is again an individual decision. Some people may come back once a year. For others, this may be more regularly, say a day a quarter - whatever suits the individuals recovery. During the four years of Starfish we have worked to build close links with speech and language therapists. We positively welcome speech and language therapists on their own or accompanying a client on a course. Many have attended the full course and learned the techniques and are now able to offer advice and backup to clients who attend a Starfish course. I have been involved now in helping people who stammer for 18 years. My lifetime dream would be to have the Starfish Project techniques available to everyone on the NHS. Till that day we operate on a cost-covering basis and will give lifetime support, as a Starfish course only initiates change which will continue after the course with all the support that we put on unconditional offer.

Small groups
Starfish courses involve small groups of people (around 10) working for the most part on a one-to-one basis with a refreshing recovering stammerer. We feel that we can respond and adjust to the individual needs of the new student this way yet still have the opportunity to carry out telephone training and role plays and to have the support of peers. Course days are generally 9am until around 6pm with plenty of breaks. We believe that this pace provides an environment to absorb and adopt the training and the new techniques. Since everyone involved in the course is staying at the same country house hotel, training (though not in the workshop) continues into the evening, with the opportunity of using the control techniques in real life situations of ordering the evening meal and after-dinner socialising. On the final day of the three day course we visit the local shopping centre in Eastbourne to give individuals the opportunity of using the technique in the real world, again always taking each contact at the individuals pace. Over the years many people have believed that if we could only find the cause of stammering we will resultantly find the cure. In an article written some 30 years ago, Frederick Murray PhD (author of A stutterers story) asks, Will the fire that is consuming a house extinguish itself merely because the match that started it has been discovered in an adjacent field? I have always referred to this quotation early on in courses as

Resources
Hood, S. (ed) (2000) Advice to Those Who Stutter (2nd ed). The Stuttering Foundation of America (publication #09, $2.00). Murray, F. (2001) A Stutterers Story (2nd ed). The Stuttering Foundation of America (publication #61, $5.00). (For both see the catalog at www.stutteringhelp.org, or contact the British Stammering Association at www.stammer.org.)

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