Book Preview: Effective Counseling
Talking with children who stutter
By Dean E. Williams, Ph.D.
Editor's Note: Dean Williams established an outstanding national and international reputation as a clinician, researcher, and teacher in the area of stuttering. As a person who stuttered himself, Williams made many significant contributions, one of which was his 1957 essay, "A Point of View about Stuttering," in which he defined an objective way to think about stuttering, while also laying the groundwork for his "normal talking" model of fluency therapy. In the "normal talking" model, children who stutter are encouraged to see their stuttering behavior as something they do to interfere with the process of normally fluent speech. In this way, they learn that the same speech production processes, used differently, underlie both their fluent and disfluent speech. From this perspective, children can appreciate that stuttering is not something that "happens to them." Therapy, then, involves helping children to become physically aware of what they do when they talk, both fluently and disfluently, and how to change stuttered speech into speech that is "normally (dis)fluent."
Dr. Williams describes a way to talk with children who stutter about their stuttering, a process that he considered integral to the "normal talking" therapy model. Specifically, Williams stated that by talking frankly and openly with children about what they believe stuttering is, why they believe they stutter, and what they think helps them to talk better, clinicians can provide them with the information they need to talk the way they want to. As Dr. Williams discusses in the following pages, these clinician-child conversations should involve an active process of directing children to observe the way they talk, and then helping them to explore their perceptions of these observations.
There is a general agreement among most speech-language clini cians that some form of counseling is appropriate for adoles cents and adults who stutter. There is not similar agreement, however, of its appro priateness for children of elementary school age. Often, there is disagree ment about what coun seling involves and how it can be "adapted" to children. Stated simply, counseling involves talking with another person. Of course a clinician talks with a child so the confusion must arise over the purpose of talking with them.
The purpose of talking with children who stutter is to discuss with them frankly and openly their beliefs about what they believe is wrong, what they believe helps them talk better, and what their feelings are about talking. Once this is determined, they need information about what talking involves and what they can do constructively in order to talk the way they want to talk. The talking that is done is structured around an active process of directing observations as the children are experiencing the ways they are talking and then helping the children evaluate and re-evaluate their interpretations of those observations. The goal is to help children explore the reality of what they are doing and to introduce and demonstrate the alternatives they have for change. Said in another way, counseling is directed toward assisting children learn the elements of problem solving with regard to stuttering.
To do this most effectively, clinicians cannot be indirect, cannot be coy and skirt around issues or topics, cannot assume the stereotype 'teacher" role of telling the children what to learn, cannot talk "down" to them or on the other hand, adopt a "professional" language that is vague at best and scary at worst.
Instead, a clinician should enter each child's language experience world and function from there. Most children will talk common sense with the clinician if the clinician will talk common sense with them.
Children who stutter generally receive much information about stuttering and many instructions of "what to do" or "what not to do" that are confusing and misleading. Before the clinician begins to explain the therapy programs to a child, it is desirable to find out as much as possible about the child's beliefs about what his stuttering is. If this is not done, the child is likely to interpret the clinician's statements and therapy activities from a perspective of distorted and perhaps erroneous beliefs of what is wrong with his speech and what he perceives he has to do to improve. Hence, as clinical activities are presented and the child filters their purposes (as explained) through his own belief system, he is apt to learn things that are different from what the clinician intended to teach. Even though positive changes in speech are attained in the therapy room, the child's ability to transfer and to maintain them in all speaking situations becomes precarious when such changes are built on a foundation of the shifting sands of confused beliefs.
Talking with the children about what they believe is wrong and what they do that they believe helps them talk better can assist the clinician in providing meaningful information about the problem. Also, it assists in explaining the purposes of the proposed therapy program that are meaningful to a child"because they take into account the child's own view of the problem. Children differ in their beliefs as to what is wrong and what is helpful. Clinicians should be aware of this. Such awareness prevents them from falling into a ritualized 'sameness" as they begin therapy with different children.
Most children's beliefs about why they have trouble talking (what's wrong) are often fragmentary and vague. Others just shake their heads and say that they don't know. Still others are quite imaginative and specific. Explanations from "words get stopped in my mouth" to "words get hooked in my throat on little fish hooks," deserve thoughtful consideration by a clinician as to their implications for what the children are trying to do as they talk to conquer the problem as they perceive it. Regardless of the reasons given by a child, they deserve and require respectful discussion with the child; not from a perspective of implying that the idea is silly or wrong or unimportant, but from the standpoint of listening, of questioning, of thinking aloud with the child what it means"of sharing with the child his dilemma. No conclusions need to be drawn at the time.
If the child seems to be confused or frightened by his uncertainties, the clinician can reflect these or similar feelings by stating something like, "It's confusing isn't" it?" Or "It's kind of scary to not have any idea what's wrong isn't it? You're trying to talk and all of a sudden things just go whambo!" The clinician can terminate the discussion by stating something like, "Look, we"ll come back and discuss this some more when we start talking about what you can do to help yourself improve the ways you talk."
The next area of beliefs to be discussed is what the children have been doing to help themselves talk better. If they have beliefs about what is wrong, the things they do to help themselves ordinarily grow out of those beliefs of what is wrong. For example, the child who stated that 'the words got hooked in his throat on little fish hooks," pushed hard in order to 'slip the words off the hooks" so he could "get them out." Clinicians should realize that children's beliefs create strong motivations for the ways they behave. If changes are attempted in the ways a person behaves without taking into consideration the motivations which prompt the behavior"even if changes are accomplished'they are apt to be unstable at best unless there are corresponding changes in the motivation for the behavior. This requires, often, an examination of the beliefs that are the guiding force for the motivation.
There are children who have no explainable reasons for what they believe is wrong, but few have no idea of what they can do to "help." Many of these ideas come from what they have been told by others. For example, two of the most common instructions they receive are 'relax" and 'slow down." The following conversations with children will illustrate the perplexing incongruity the children face between what they try to do to help, what they do, and their explanations for it.
First child in a conversation with the clinician.
SLP: 'so, you're talking along and all of a sudden you stutter. Why do you suppose it happens right there?"
C: "Oh, I stutter when I talk too fast."
SLP: "You do? How did you find that out?"
C: "Well, when I stutter, they tell me to slow down."
SLP: "Mmm-hmm, do they even tell you to slow down when you don't stutter?"
SLP: "Why do you suppose they don't?"
C: "I guess it's because I must be talking slower."
SLP: "Oh, I see. Well, what do you do to help yourself when you talk?"
C: "I try to slow down so I won't stutter."
SLP: "Does that help?"
C: 'some of the time."
SLP: 'some of the time?"
C: "Yeah. You see, I don't stutter all the time."
Second child in a conversation with the clinician:
SLP: "You say you stutter some. What do you do to help at those times?"
C: "I try to relax."
SLP: "Oh, why do you do that"are you real tense?"
C: "I don't know'they tell me to relax so I won't stutter."
SLP: "Does it help?"
SLP: "All of the time?"
C: "Yeah, except when I stutter."
SLP: "Mm-hmm. What do you do then?"
C: "I just stutter."
SLP: "And then what do you do?"
C: "I just don't talk for a while."
SLP: "You don't talk for a while, I see. Don't you feel like talking, or what?"
C: "I feel kinda bad. I don't want to talk until I feel better."
Again, as with the earlier discussion, there is no need for the clinician to confront and resolve the child's beliefs at the time. The clinician, again, can reflect the child's feelings and possible confusion.
The example of the second child illustrates also how these ways of talking with a child open the door to discussing the child's feelings about stuttering and about himself. For younger children, the feelings are predominately ones of feeling "bad" or 'sad." The overriding emotion is one of frustration. Strong embarrassment surfaces with many as they get older. The things they do to help are inconsistently helpful (according to their perceptions) or lead to more difficulty. An example of the latter is the child who said he helped by just pushing the word out. When asked what he did when that didn't help, he replied, "I push harder." They become frustrated because they are doing the only things they know to help themselves"and these things are not too helpful. This leads to doubts about their ability to cope. They are experiencing conflicts about what to do. Things are not working the way they intended. They are developing feelings of helplessness. This is scary to them.
What's Going On?
When a clinician begins to share the particular view that the children have about what is wrong and what they can do to help themselves talk better, it should become obvious that the children need constructive information about what's going on. Stuttering appears to them to be very mysterious. They are confused by it. They are likely to feel that they are "defective": or that something is horribly "wrong with them." They can begin to feel that they are "dumb" or "incompetent" because they cannot overcome the 'thing" by gritting their teeth and trying harder. After all, most adults seem to know how they can stop doing it. The children are told, for example, that if they would only 'slow down" or 'relax" or 'think of what they are going to say," they wouldn't do it. It sounds so easy. Yet when they try it, they fail. There appears to be little, if any, relationship between what they do to help and the result of what they do. The trouble must be with them.
The clinician has a responsibility to each child to help him learn "what is going on""what accounts for this disparity between what the child is trying to accomplish and the result. Or, said in a more constructive way, the clinician should help the child learn the relationship between what the child is doing to help and what he is doing to interfere with his speaking. Moreover, it should be done in ways that the child can understand. The word "understand" is used not to refer to a relatively abstract intellectual understanding, but to one based on the child's own world of experiences. He must be able to relate this "understanding" to his everyday activities.
Too often, clinicians begin by talking and philosophizing about stuttering by attempting to define it. This results in an explanation that includes the statement, 'there are many different reasons given for stuttering. No one knows, for sure what causes it, but we"ll do what we can to help you."
This type of explanation easily can convey to the child that the clinician is as confused as he is, but something will be 'tried." The compulsion that we have in our profession to discover 'the cause" spills over into our clinical procedures. The child is not interested in the confusion among stuttering theoreticians. He wants to know "what is going on" when he begins to talk and what he can do about it. This is reasonable. Instead of attempting to define stuttering, we need to explain to the child "what's going on" in a way 1) that reassures him that something terrible is not wrong with him and 2) conveys a positive direction involving constructive learning experiences.
My own personal preference is to explain it in terms of learning. The child is in the midst of the experiences of learning. He is learning at school, he is learning to get along with friends, he is learning, learning, learning. He knows what it means. Moreover, there is little doubt that learning is normal. At the same time, it can be explained in ways that do not violate most responsible theories about the development of the stuttering problem. An example of the essentials of such an explanation follows:
Stuttering is a confusing thing to most boys and girls. It's tough to know what one can do about it. It seems at times it's almost like a "burp." You can feel it coming and, whoops, you burp! About the only thing you can do is press your lips tightly together so it won't sound too loud"or put your hand over your mouth so people won't notice it too much. Although stuttering may seem to be something like that, it really isn't. Stuttering is something you began to do when you were learning to talk. We all have to learn to talk"just like we have to learn to read or do arithmetic. When we learn, we make mistakes. This is a normal part of learning anything. It's true with learning to talk. Examples are demonstrated of different types of dis-fluencies which make up the mistakes of talking. It's no different from learning arithmetic. Some children make more mistakes than others when they learn arithmetic. Some make fewer. The same is true with reading"or with talking. But regardless, as we practice and learn, we get so we can do arithmetic, or read, or talk OK.
You probably made more mistakes when you were learning to talk than some of the other children did. You didn't want to make so many so you began to fight them. The harder you fought, the more mistakes you made. It's kind of like learning to catch a ball. (Or any other similar type of behavior.) If you try hard to "not drop the ball""or tense up and "pounce" at it so you won't goof, you drop it more often. This is the way it is when you do what we call 'stuttering." You fight to say it right. When you fight, you tense, you may pounce (quick increase in velocity of movement). Or you may generally "hold back." When you do this you tense, maybe hold your breath and get set to "fight any mistakes you may make." This is a very normal reaction"a normal way to fight mistakes. You're OK. There is nothing inside you"in your mouth or throat or stomach that stops a word. You learn to fight your speech. You can learn to talk smoothly.
The above explanation is not presented in a monologue. One includes the child in the discussion by asking if he understands, by asking for other examples, etc. Finally the clinician models different types of disfluencies, then asks the child to do them. Then the clinician models fighting them in different ways and asks the child to do the same. This aspect may take several therapy sessions. The child must experience them, explore them, puzzle over them as the clinician and the child discover what he's doing. This then leads into comparing them with what he does during any 'real" instances of stuttering. He needs to explore all the facets of the similarities and differences between the "fighting" he does in specified ways and the occurrence of a 'real" stutter. The clinician needs to talk with him and examine them too. It's a period of learning, of discovery, of realization that he is doing these things. This is the foundation upon which the task of establishing congruence between intent and resulting behavior is learned.
The next necessary learning experience is to discover that as he changes the ways he "fights," he changes the result"or, the characteristics of the stutter. He should tense up more, then less. He should speed up the velocity of movement, then decrease it, etc. He should talk and not fight so hard when he 'stutters." The clinician should be involved by modeling the changes then asking the child to do the same thing. This establishes the foundation for change. It involves learning that the reality of changes is dependent on what the child does. This opens the door for improved self esteem, for the development of taking responsibility. The child can learn that he has something to do with what he does" and that what he does determines what "happens" when he talks.
The purposes of the activities described above should not be confused with those of "desensitizing to stuttering," or with those of "accepting one's stuttering." These are not designed to show the child that he should talk that way out in social situations. They are not therapy techniques aimed at the immediate production of fluency. They are structured experiences designed in order to guide the observations the child is making. As he makes them, his perceptions and evaluations can be discussed with him. Different interpretations can be suggested by the clinician and then immediately tested. They can be a most effective method of counseling with children regardless of the therapy procedures employed by the clinician to improve fluency. It requires the child to discuss and evaluate his experiences in the reality of the present instead of from the unreality of his remembrances of the past.
The experiences and discussion described above will ordinarily bring to the surface the child's sensations of emotion. These can be shared and discussed openly. The clinician can lead such discussions in the direction of helping the child learn that attending to and changing one's behavior is dependent on what the child does and is not dependent on reducing or eliminating one's emotions. He can learn that he can change the way he does things in the presence of emotion. This is one of the most effective ways for a child to cease depending on his "feelings" to tell him how he will talk. By so doing, the way he "feels" becomes less important and what he does becomes more important during the process of talking. Hence, his awareness of "feelings" diminishes.
What Do We Do to Talk?
The question of "What do we need to do to talk?" naturally follows from"or blends into'the above discussion. For the clinician a more meaningful question is, "What does the child have to do to learn correspondence between what he intends to do and what he does?" Too often clinicians attempt to answer the question by imposing on the child a special speech pattern (either of fluency or of stuttering) in order, hopefully, to heal his wounded speech. This approach, it seems, reflects the clinician's limited perspective as much, or more, than it does the child's abilities or inabilities. Such an approach takes advantage, apparently without recognizing it, of the child's beautiful ability to cope and to adapt to a wide variety of ways of talking. Clinicians differ in what they preach and teach. Some extol movement, others air flow or relaxation, or slow movement, or smooth stuttering, or smooth transitions, etc., all with varying degrees of success. The wonderment of it all is that the poor child is able to cope with any or all of these cross-stitched sutures and still talk.
In order for the child to learn to be responsible for the ways he talks, it is important for him to problem-solve about what he does that helps him talk and what he does that doesn't help"in fact, what interferes with talking the way he intends. From his exploration of the behavior used to fight mistakes, he is aware that such things as tensing too much, holding his breath, etc., make talking difficult or impossible. It's time to learn what we do when we talk. This involves providing information about what the process of talking involves. "Providing information" does not include teaching him on an intellectual level the technicalities of speech production. It involves explaining, demonstrating, experiencing on a doing level the process of blending air, sound, movement, timing, tensing into the production of what we call words, phrases and sentences. Here the clinician can move into each child's beliefs of what he thought was wrong and what he did to help (discussed earlier) into the reality testing arena for accuracy testing of his beliefs.
Permit the child to test and discover for himself. Don't just tell him and expect him to "know it." If you do so, the child may know it intellectually but he won't know it in an operational-doing way. He needs to learn by experiencing that what we call a word is created primarily by a movement sequence of tongue, jaw and lips imposed on air or sound. Words don't come out of the throat or stomach. He needs to learn by experiencing the way we begin to talk'the initiation of movement with sound or air, the proper amount of tensing necessary, etc. This explanation cannot be done effectively at the level of the words. The clinician leaves the level of words and relies on experiencing and doing"punctuated by words only to direct the observations that are to be more meaningfully experienced.
By experiencing the things necessary to do to talk the way he intends, it becomes more meaningful to contrast these to different things he can do to interfere with the desired process. He can learn the relationship between tensing and increased velocity of movement, between restricting air and the production of sound, etc.
In summary, he learns what we do to facilitate talking and what we do to interfere with it. Furthermore, he learns that stuttering is not something that erupts out of his mouth but, instead, consists of things he does to interfere with talking all along the vocal pathway. In addition, he learns that he can change what he is doing as he is talking so that it more nearly conforms to what he intends to do. By the continuous attending to the reality of what he is doing and knowing by experience what will help and what will hinder, he has the time to change in the ways he desires. This results in his learning that he has a choice. He is free to act in accordance with his choice. This is the goal of obtaining congruence between what a person intends and the way he behaves.
The intent of this approach to counseling through experience is to ensure in so far as is possible that the child can participate in a program to improve his fluency in a positive, matter-of-fact way. The counseling becomes an integral part of how the clinician helps the child to improve his speech. The child should possess the basic orientation that talking smoothly involves an active doing process to be learned"with the acceptance of the mistakes that accompany any learning.
This excerpt by Dean E. Williams, Ph.D., is from Effective Counseling in Stuttering Therapy.
Copyright (c) 2010 Stuttering Foundation of America.