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Thoughts on the European Symposium on Fluency Disorders 2012

Max Gattie, Susan Clark | 01.04.2012

Manchester self-help group member Max Gattie comments upon presentations held at the 3rd biennial event in Belgium, and suggests therapy contributions of his own. Below that, Susan Clark SLT reports on Trudy Stewart's presentation 'Bridges'.

Squirreled away down an Antwerp side street is Lessius College. Since 2006, this has been the headquarters of the European Clinical Specialisation Fluency Disorders (ECSF), an initiative to harmonise qualifications for work with adults and children who stammer across Europe. To this end it hosts a biennial conference, split across research and clinical developments. This kind of event, gathering parties from around the world, really is the lifeblood of attempts to understand stammering, and it was with some anticipation that I boarded a flight to Belgium in March.

You can see all of the presentations - including mine - online at www.ecsf.eu(1); it's a great place to spend a couple of hours. In what follows I'll give a selective account of proceedings. There was too much for me to cover so I've picked out a few things I think are important.

Research developments

Deryk Beal gave an overview of brain activity in stammering. A common finding is that it switches from the left to the right hemisphere; there is other unusual activity as well. But this raises a tricky question: are we looking at the activity and physiological difference that's causing outward displays of stammering, or are the changes in brain activity and morphology merely attempts to cope with the stammering? You could even get both effects happening on top of each other. We can investigate further with tests on children; since their history of stammering is shorter, we'd expect long-term effects to be accordingly lessened. Studies like this are ongoing.

Typically, explanations of stammering focus on abnormalities. Certainly, people who stammer have very obvious problems in these areas. But I can't help thinking that this misses the bigger picture of the large amount of fluent speech you can observe in all but the most severe stammering. Any complete theory of stammering will need to build in this variability from the outset. It wasn't at all clear to me how presenters intended to do this, and I'd suggest that future work should focus on this area. Of course, I'm bound to say so because that's what my presentation was about - I'm hardly an impartial bystander.

Therapy contributions

I'd like to suggest a new way to tackle the therapy debate. I think it's easier to understand mainstream therapies by looking at what they have in common. And I suggest that this is the insertion of deliberate prolongations(2) into speech. For people who stammer there are three ways to do this:
1. On every sound;
2. On sounds where you think you'll stammer;
3. On sounds where you don't think you'll stammer.

If you're doing 1., it's fluency shaping; 2. is block modification; and 3. is voluntary stammering, which isn't a type of therapy but may be used as a component of one. It's in the difference between fluency shaping and block modification that the discussion usually falls. By the way, I should point out that there's a bit more to both therapies than what I've described above (e.g. both should involve some psychotherapy, relaxation techniques, etc). It's just the similarities in phonation I'm focusing on here.

European Symposium on Fluency Disorders 2012In Antwerp, Susan Block represented the first approach, and Trudy Stewart the second(3). Both are expert therapists at the very top of their profession (see 'Bridges' below for an outline of Trudy's presentation). But I can't help preferring approaches centred around block modification. This follows from the explanation above. It turns out that fluency shaping is logically a limiting case of block modification therapy(4), one in which the modification is applied pre-emptively to every sound. This may be the ideal solution for some - indeed, I think it is, and Susan showed a video of one case. The problem is, it won't be the best route for everybody. In particular, it won't do for those who are put off by the therapy's more robotic aspects arising, as they do, both in the manner of instruction and in the initial form of the fluent speech. Fluency shapers will reply that you can get around this.  With a good therapist like Susan, sessions will be productive and speech should regain its usual prosody fairly quickly(5). But why force all stammerers into such a clinical straitjacket? Can't they choose the type of therapy that's best for them? Maybe the total elimination of stammering isn't even an appropriate goal. I think the early meetings should thus be ones of guidance, not prescription, with both parties agreeing the form of future work from the full range of options available.

I should say why I think this matters. Readers can hardly have missed the changes that the government has imposed on the NHS, ignoring public and professional opinion. The ramifications are difficult to predict, but adherence to the plan would increase granularity in service provision. As such, and with Primary Care Trusts already abolished and GPs hard-pushed to fill the breach, reliance on general business measures (sometimes called 'evidence based practice') would follow. In such a world fluency shaping is poised to become the therapy of choice. It can be delivered in a highly prescriptive manner, and with the precise measures of success (i.e. via reduction in syllables stammered(6)) beloved by business. It's a bit like the production line delivery of perfectly-shaped mannequins. As outlined above, I think such a dissolution of choice would be retrograde for people who stammer.

Round-up

There's a lot I've been unable to cover: Ludo Max on motor control, Marilyn Langevin on adolescents, Paul Brocklehurst on linguistic approaches, Joseph Agius on use of humour, just to mention a few. You can see these and more on the website (footnote 1 below). The conference itself will be back in 2014 and is well worth a visit.

Footnotes:
1 You can see all the presentations at www.ecsf.eu/news-and-events/european-symposium-on-fluency-disorders-2012...
2 Or you could use repetitions instead. This would be the Wendell Johnson 'bounce' technique, and it ties in with the idea that either prolongations or repetitions are primitive to stammering.
3 This isn't quite accurate, since Trudy actually offers a holistic approach which includes fluency shaping if appropriate. But if you follow along with the rest of my argument, you'll see that I view this as an outgrowth of block modification anyway.
4 Consider that Van Riper's Treatment of Stuttering (1973) - the locus classicus for block modification therapies - is as much a collection of anecdotes as anything else. You can read it as a suggested sequence for the therapist to improvise around. Indeed, speech typical of fluency shaping is specifically addressed during the identification and variation stages. Thus working out a programme for someone which happens to focus on fluency shaping could easily fall within the auspices of block modification.
5 Indeed, it seemed to me that Susan demonstrated the typical prosody resulting from fluency shaping throughout her talk. If so, this is commendable.
6 And an unfortunate side-effect of this is that in some implementations where professional standards are scanty or absent, failures can be blamed on the person who stammers. This is deleterious, and motivational conflicts should have been addressed before the start of therapy proper.


'Bridges'

By Susan Clark, the Stammering Support Centre

Trudy Stewart, Consultant Speech and Language Therapist at the Stammering Support Centre, delivered a reflective piece titled 'Bridges', which explored the therapeutic alliance between the client, setting out on a therapeutic journey, and the clinician, supporting the client in planning and managing that journey.

She began by introducing the metaphor of bridge building, discussing the variety of structures and components to utilise as well as surveying the terrain and determining the crossing points. A bridge is central to moving across boundaries. Likewise, a successful therapeutic partnership is based on a secure, yet flexible connection, developed and maintained between clinician and client.

Trudy described clients' journeys through therapy which may include negotiating 'difficult terrain', and the client finding themselves in places where they feel vulnerable. The client-centred clinician listens, accepts and supports the client to set their own agenda described in the manner of bridge building, ensuring that the structure is established on secure foundations, is able to withstand adverse conditions and is well placed to be useful to reach the place the traveller wishes to arrive at.

The analogy of bridge building representing the client/therapist partnership is evocative of the concept of a journey. A traveller reaching a bridge is leaving one place and going towards another. On the way, the support of the bridge is required but is no longer needed on arrival at the other side. Like the bridge, the therapeutic alliance has a start and an ending.

The presentation was an insight into many years of Trudy's own reflective practice, and encouraged the listeners to consider what goes on in therapy and to reflect on their own understanding of the processes involved.

From the Spring/Summer 2012 issue of 'Speaking Out', pages 16 and 17