Models of Therapy

Mind your Ps and Qs is an English language expression meaning "mind your manners", "mind your language", "be on your best behaviour", "watch what you're doing".

• To our self.
• To others.
• How we talk about children who stutter.
• How children who stutter hear us talk about stuttering generally.

Action: helpful self talk to counter stereotypes.

• Gather evidence in real-life situations will lead to generating more balanced thoughts on the basis of their findings.
• People can identify helpful self-talk that will positively influence their emotional reaction and behaviour in a situation.
• Helpful self-talk can also be generated by reflecting on previous experiences that have gone well and what the person was saying to himself or herself at the time.

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For the Speech and Language Therapist

• Be aware of own thoughts, feelings and expectations around stuttering and our role as an SLT.
• Communication trumps fluency.

Action: helpful self talk.

• Handouts for teachers.
• Powerpoint for school presentation.
• Advice leaflet for parents (Generate discussion about what works in therapy  and helpful versus unhelpful advice).

The Questions we need to ask

Who needs to change? What do they/we need to change?

Acknowledging the natural variation, the unique skills, experiences and traits of neurodivergent children.

— Constantino (2018)

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Client who stutters

What do they understand about stuttering? And their stuttering in particular?

Cons for the Client

• Exposure: "I stutter".
• Risk of failure.
• Lack of acceptance by self and others .

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The Speech and Language Therapist

What do we understand about stuttering? Turn the tables on the process of normalising judgement As therapists we need to enquire into what a person thinks of the judgement they have been assigned. What if stuttering was the norm? If stuttering was cool…

Cons for the Therapist

• Exposing beliefs contrary to the medical model.
• Perceived risk of ‘failure’.
• Lack of acceptance by peers, clients and client's families.

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Who needs to change?

How do we do this? Is this our responsibility alone?

• Ourselves as SLTs
• Families.
• Parents.
• Teachers.
• Employers.
• School systems.
• Health services.
• Shop keepers.

In our zeal to resist medical conceptions of stuttering do we just substitute one normalizing litmus test for another?

By rejecting fluency in and of itself or by asking whether forms of knowledge are consistent with our favorite model of disability, what ways of being do we disqualify?

I’m not comfortable telling another stutterer how to think/feel about their stuttering.

Stutterers are always already resisting how they are constituted.

How are they currently resisting societal demands for fluency?

How are they currently resisting their body’s demands for effortful speech?

Rather than see therapy as a means to liberate the self (be it fluent or stuttered) I suggest we see it as an exploration of the stutterer’s resistance and agency.

We explore how the stutterer has been constituted not to determine who they must be but to determine who they do not have to be.

We explore how they got here but leave where they’re going up to them.

In my clinical experience, most stutterers value both an increase in their ability to resist societal pressures to speak fluently and an increase in fluency, or at least easier stuttering.

• Fluent ↔︎ Stuttered
• Medical models ↔︎ Social models
• Speech restructuring therapies ↔︎ Neurodiversity

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Authentic self as fluent

Authentic self is repressed by bodily power (pathology). We can liberate the self by restoring normal functioning.

• Behavioral therapy.
• Medication.
• Surgery.

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Authentic self as stuttered

Authentic self is repressed by social power (ableism). We can liberate the self by rejecting fluency.

• Stuttering pride.
• Activism.
• Creative expression.
• Identity is always relative.

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Identity is always relative

There is no true self to be emancipated, there is only different selves constituted through power relations.

I am constantly being encouraged to pluck out some one aspect of myself and present this as the meaningful whole, eclipsing or denying the other parts of self.

— Lorde (1984)

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A rejection of authenticity does not necessarily lead to determinism.

We are free in so far as we continuously rebelling against the ways in which we are already defined, categorized, and classified.

Albert Gutzmann (1837–1910)

• Published article on stuttering, Treatment of stuttering by organized and practically proven method (1879).

Hermann Gutzmann (1865–1922)

• Son of Albert Gutzmann.
• Medical doctor.
• Considered ‘The father of logopedics’.

Emil Froeschels (1884–1972)  

• Founded the International Association of Logopedics and Phoniatrics in 1924 (IALP).
• Stammering as psychological origin.
• Chewing method.
• Incorporated different theories.

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1931 – University of Iowa researchers, psychiatrist Samuel Orton (1897–1948) and psychologist Lee Edward Travis (1896–1987)

• Cerebral Dominance Theory of Stuttering.

1940s – Wendell Johnson (1906–1965)

• Diagnosogenic theory.
• ‘Anticipatory hypertonic avoidance reaction’.

1972 – Charles Van Riper (1905–1994)

• The Nature of Stuttering (1972).
• Stuttering stigma.
• Learning theories.
• Attitudes.
• Psychogenic desensitization.
• Neurogenic: acquired ‘Hesitation Phenomena’.

1959 – Howard Maclay and Charles E. Osgood

• Filled and unfilled pauses, repeats, false starts

1969 – Howell & Vetter

• '… cognitive complexity of the utterance…’

1961; 1968 – Goldman-Eisler

• Pausing.
• Interjections.
• Repetitions.
• Tempo changes.
• ‘Normal’ non-fluencies: filled and unfilled pauses 30% of the time.

The speech-language pathologist is the professional who engages in clinical services, prevention, advocacy, education, administration, and research in the areas of communication and swallowing across the life span from infancy through geriatrics.

— The American Speech And Hearing Association (ASHA) (2007:1)

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Identity


• Etymological root refers to sameness but often seen as what makes me unique – who I am.
• Medical model/social model.
• Narrative Practice – viewed as “public and social achievement”.
• Co-constructed in “the trafficking of stories about our own and each other’s lives” White (2007, 182).

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The process of professional identity

• Individual process but co-constructed.
• Multiple identities.
• Fluid, dynamic.
• Therapeutic exchanges.
• Stories told and interpreted.
• Cultural Influences.

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How are identities constructed?

O’Dwyer and Leahy (2015)

• Postmodernist thinking – multiple identities are available to an individual at any given time.
• Narratives play a large role in how we construct and re-construct these identities for ourselves and for others.
• Narratives are how we make sense of our experiences and this meaning-making in turn leads to a sense of identity. Bruner (1986: 143) explained that ‘narrative structures organise and give meaning to experience’.  Riessman(2008: 8) states that ‘individuals and groups construct identities through storytelling’ and that these identities are fluid.

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SLTs – multiple identities*

• An individual speech and language therapist has multiple identities available to them at any time.
• More aware of some than others and how conscious/aware they are of any identity at a given time varies.
• Intrapersonal and interpersonal factors influence how these identities are negotiated and renegotiated.
• These identities are negotiated in their interaction with the people they see for therapy and their families/carers.
• “Through clinical interaction clients and clinicians negotiate who they are and the roles they play in the therapy story.” Simmons-Mackie and Damico (2011:44)
• If a particular identity gets validated through these interactions, it takes hold and is performed regularly, If not validated, gets renegotiated.

*O’Dwyer, M.  and Leahy, M.M. (2016). There is no cure for this:  An exploration of the professional identities of speech and language therapists’, Journal of Interactional Research in Communication Disorders, 2, 149-167.

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Who are speech and language therapists working with children and adults who stutter and their families?
 Possible identities:

• Disability viewed as a human rights issue.
• Direct challenge to the medical model & institutions within which most SLTs have been trained and work.

Calls into question:

• Principles upon which therapy is based.
• Roles of therapist/client.
• Language.
• Range of therapies offered.
• Types, forms and aims of research into stammering.

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If speech language pathology is the intervention that stuttering activists seek from the government, medicine and private sphere, there is at least a conversation to be had about its medical necessity […] The stutter itself is only a negative bodily development if making people occasionally wait an extra two to ten minutes is a pathological emergency. This is all just to say, the burden should be on speech pathologists to prove their legitimacy on something more than merely auditory aesthetics.

— Richter (2019, p.73-74)

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Call for action

• Ethical responsibility.
• Locating therapy discourse within wider disability/neurodiversity discourse.
• Call for broader focus of therapy to address roles that self-identity, society and social stigma play.
• Drive to enrich and enhance professional accounts.
• Co-authoring therapy knowledge.

• Facilitating cultural competence and awareness
• Understanding the dynamics of stigma, self-stigma and masking and the psychological consequences of living with a concealable stigmatised identity
  
• Exploring the lived experience and feelings associated with stammering in an ableist world that privileges fluency
  
• Understanding minority stress and ableist trauma
  
• Supporting the development of new affirming narratives around stammering
  
• Finding own unique stammering aesthetic
  
• Disclosure and self-advocacy
  
• Community

• Public information and education programmes
• Reducing barriers – creating a stammer-friendly environment and culture
• Campaigning
• Lobbying
• Representation
• Cultural change
• Celebration of stammering and difference