When we consider “One Size Does NOT Fit All” as speech-language pathologists (SLPs), what is our role in stuttering treatment?
Conventional wisdom in the sub-field of stuttering evaluation and treatment calls on clinicians to meet their clients (and families) where they are. Change cannot be forced on anyone, and as clinical psychologists William Miller and Stephen Rollnick have argued, those who are not yet ready to change will simply supply their own arguments against change (Miller & Rollnick, 2013). This will inevitably lead to behaviors which support those arguments. In other words, change must begin internally, manifest its readiness in language, and then lead to sustained action. This view comports with the available research and encourages speech therapists (in our case) to start with the client rather than a preconceived and rigid plan of action. One size simply does not fit all.
Yet, there seems to be some confusion over the well-known principle: meet clients where they are. Many in the field use this language synonymously with a call to “do as clients wish,” whatever the request and whatever the consequence, thus decontextualizing its potential benefits. It is this latter implicit direction which fails to take into account the very nature of stuttering and its impact. An open-ended conversation with a person who stutters can yield the problems associated with stuttering: shame, guilt, embarrassment, fear, anxiety, saying less, staying home, hiding, hopelessness, concealment, unwanted thoughts, diminished self-worth and confidence, dread of conversation, and physical exhaustion. While this list is far from exhaustive, it is intended to paint a picture of a life which is ruled (in many cases) by stuttering or even the possibility of stuttering–a life in which decisions are made to minimize social stigma and other potential consequences of being a person who stutters. The bad news is that these are not hypothetical consequences for stuttering in our day and age. The good news is that none of these consequences are endemic to stuttering and thus, can be discarded and changed if desired.
Speech therapists possess a unique mixture of specialties in motor speech, counseling, pragmatics, and behavior change, and are in an excellent position to support people who stutter. We can do this by asking open-ended questions to elicit their personal experiences, challenges, resources, and hopes, all from the perspective of a person who stutters. However, we do not merely want to understand their problems or the nature of their problems. We also want to understand the types of change (if any) they desire to make. Broadly, this may sound daunting, or conversely, intuitive until beginning the conversation, only to find that this is easier said than done.
Given the nature of the problem, it is important to know how the client views his or her communication and what he or she is prepared to do about it. The response by most newer clients (or families) is that stuttering is the problem and fluency is the solution. In most cases, clients have not considered the problem beyond these bookends: stuttering and fluency. Many clients appear to lack an imagination beyond an undefined future hope: fluency. When asked what this would mean for them, many struggle to expound on their initial responses. “What would your family notice (or notice you doing) if you didn’t stutter anymore?” Many respond, “Well, they would notice that I’m not stuttering.” This response and many like it evidence a belief that there are only two choices: to stutter and live as “broken” or find fluency and finally begin to live. These choices will be expressed in myriad ways but evidence the same core belief that speech fluency is the only way out of their problem(s). If clinicians simply “give the client what he/she wants,” it will feed these false beliefs and reinforce the notion that fluency will give them what acceptance cannot. If we, instead, pivot to probing their experience of stuttering and the future they envision (if stuttering were no longer an impediment to living the life they want), both client and therapist will begin to peel back the facade of the “fluency solution” and discover the gems hidden below the surface. We simply have to be willing to mine with them.
We intend to argue in this paper that it is the job of the therapist to elicit insights into the nature of stuttering and explore associated problems with clients and to illuminate the variety of choices for communication with guidance in achieving whatever desired outcome is expressed. The key is “informed desired outcome,” but what do we mean by this? As aforementioned, sometimes the individuals we serve, young and old, come to speech therapy with a valid desire, even need, for fluency that is often informed by a limited view and understanding of stuttering. This is heavily influenced by recurring negative listener reactions, trauma experienced due to stuttering, cultural views surrounding differences, societal norms of what is acceptable or preferred, as well as internal and external pressures for fluent speech. Let’s imagine for a moment the first time one experiences the ocean. What’s the difference between swimming in a lake versus swimming in the ocean? You might be content with lake water if you know nothing different, but once you’ve seen and experienced the clarity and beauty of the ocean, it’s unlikely you’ll desire lake water again. What if our role as SLPs was to guide our clients/students to see the beauty of the ocean of spontaneous and joyful communication rather than remain in the murky waters of fluency at all costs? A shift of this sort would see SLPs as guides in expanding a client’s imagination of what is possible, slowly removing the blinders to enable them to see the panorama. Seeing a possible preferred future which was previously unimaginable can lead to hope, the belief that what is possible might be probable. And increased hope can lead to genuine choice. After all, who chooses an option which they believe is not truly possible?
It is here that an important qualifier must be added and that qualifier is this: each client brings unique personal experiences, readiness, personalities, values, and personal resources which will impact and inform the change(s) they make. It should be noted that this is an aspect of meeting clients where they are which should be upheld. Clients must have complete autonomy over their treatment and the pace of the work, even while clinicians play a role in shaping that experience and coaching or guiding clients toward their preferred future.
Joze Piranian, speaker, comedian and person who stutters, presented a similar idea with a different lens when giving a keynote address at the 2023 NSA conference. He shared a quote by Persian poet Rumi, which speaks to the work we do with people who stutter, “Why do you stay in prison when the door is so wide open?” As SLPs, it’s a beautiful picture of the power of treatment when we help people finally see wide open doors in order to come out of whatever “bondage” they find themselves in (i.e., limitations, restrictions, confinement due to stuttering).
In a recent video depicting positive outcomes of effective speech intervention (https://youtu.be/l4pddgtEH3g), Mike conveys such a powerful message, stating, “After my perspective changed, I pretty much stopped worrying about it (stuttering), which is really something I’ve been seeking my whole life which I didn’t even know that I was seeking for it, so it was a huge help in just a perspective change on my entire social interactions.” Mike didn’t even know that what he was seeking in treatment was freedom–freedom from a mind consumed with stuttering (or not stuttering), freedom from the shame he experienced, freedom from the pressure he felt to speak fluently and never stutter, and to “get this fixed” so he could finally achieve his goals. For the first time, Mike understood the false dichotomy between “either fluency or…dating/marriage, a career, friendship, participation, independence (or fill-in-the-blank).” He describes this change as an inward change–an inward change he never knew was possible. In other words, his speech therapist helped him consider possibilities and outcomes he didn’t know existed. If his therapist’s approach had been to simply give him what he wanted (i.e., tools to reach fluency), his vision for his life would have remained restricted and narrow.
We will presume you are fully convinced by this line of argumentation and speak to the “how” of expanding realms of possibility in everyday life. Motivational interviewing and solution-focused brief therapy provide helpful models of questioning which ask the client to “use your imagination” to discuss what might be different if the problem were suddenly gone. The focus is on positive solutions to the problem at hand, what the person would be doing that he or she is not doing now, or is doing now but might hope to do even more. The therapist reflects these responses back and provides additional questions to “mine” for concrete behaviors (gems) which might become actionable. For example, responses such as “I would be happy” or “I wouldn’t feel so afraid” are insightful but offer no clear opportunities for concrete change. The clinician might then ask, “If you were happy, what would be different?” or “If you felt happy, what would that free you up to do?” Solution-focused therapy often utilizes the question, “And what difference would that make?” or “Suppose that happened, what would be different?” to delve further into this hopeful future. These conversations often generate lists which can be shaped into goals and insights into the changes a client would like to make. I want to talk more, I want to give better eye contact in presentations, I want to have fuller conversations (rather than cut them short or say as little as possible), I want to ask questions in class. These responses reach far beyond “fluency” and into the everyday life of a client. In the same way a client may state, “I want my stuttering to go away” or “I want to be more fluent,” a client may also state, “I want to introduce myself to new kids at school.” Unless SLPs ask the question, many people who stutter might never share these hopes. Indeed, a client might never voice these hopes because he or she does not consider them worth uttering. The key is taking small, tangible steps over time which lead to meaningful changes. Books and articles by William Miller, Stephen Rollnick, Kidge Burns, Insoo Kim Berg, and Steve de Shazer, can help to flesh out the methods discussed briefly in this paper in greater detail.
In summary, “One Size Does NOT Fit All” means that it’s not only ethical and reasonable for SLPs to serve as guides to worlds unexplored, but it is our role and responsibility to do so. We carefully cultivate a culture in which change is viewed as possible and in which desires, needs, and hopes can be actualized within and beyond the therapy room.
