Conscious Synthesis of Development: A Holistic Approach to Stuttering


Starting from this multidimensional view of humans and bearing in mind the diverse symptomatology in people who stutter, Brajović and Brajović (1976, 1981) developed the CSD method, or Svesna Sinteza Razvoja in Serbian, which was a synthesis of the approaches to stuttering current at that time (Beck, 1975; Van Riper, 1973; Wolpe, 1958). The name comes from the approach taken to address holistically the person who stutters (Brajović et al., 2010).


Within the original CSD approach it was assumed that disorders such as stuttering can be overcome, but also that one cannot change them if clients are not fully aware of them. This is why it was postulated that, first, the disordered functions must be consciously identified and people who stutter must become aware of their physiological and psychological functioning and relevant environmental factors through sensations, feelings and behaviours. Second, by copying the natural development of these functions, they are consciously developed or returned to the level they were at before stuttering occurred, in other words, to an adequate way of functioning. The client uses conscious awareness to integrate these newly developed or redeveloped functions in a harmonious interplay.


Demonstrated value


Expected therapy outcomes differ for different clients. In most cases, the expected outcome is to achieve a significant decrease in all aspects of stuttering. The aim of therapy is for the client to take control over their speech and to be satisfied with their functioning in most speech situations.


In the 1970s there was research done with the approval of the US government, which showed that the method is successful in dealing with speech and concomitant problems in clients who strictly followed the methodology (Brajović and Brajović, 1981; Brajović et al., 2010). The research stressed the importance of parents and other significant people being included in the therapy. Recently, we have been conducting new research and our data so far also show that most of our clients benefited greatly from the programme (Šoster, 2003; Šoster et al., 2007; Tadić et al., 2010). The data here include these sources and in addition, recent data from one group of 140 clients, which has not been previously published.1 These are file audit data taken from routine CSD treatments. Some clients do not return for treatment after initial diagnostics, and some clients do not complete their treatment. We present only data for those clients who completed treatment.


The initial data that are presented in Figure 16.1 were collected not at pre-treatment but during the first day of residential therapy, at which time clients’ stuttering had decreased because they had attained some control over their speech. The final data were collected on the final day of residential treatment. Most of the data are from clients during Phase II.


In Figure 16.1, the number of stuttering events were based on 300 words spoken in the clinic while reading, retelling, enumerating and conversation. The stuttering events were counted in real time by a clinician. The subjective distress in situations is based on a list of 18 common speaking situations (Šoster, 2003). Clients use a 100-point Subjective Units of Distress scale based on Wolpe (1969) and refined by Radonjić (1982): ‘0’ means ‘total peace’ and ‘100’ means ‘state of panic’, meaning that the client is incapable of being in that situation. For each of the 18 situations, clients assign a Subjective Units of Distress score, and a mean score is established for each client. The mean of scores for clients is presented in Figure 16.1. The stress caused by listener reaction is a similar scale of 13 common listener reactions (Tadić et al., 2010), which is again scored with the Subjective Units of Distress measure. For the latter two scales, all clients are invited to make them shorter or much longer, depending on their own experiences.


All measures showed reductions of scores from initial to final assessment. Number of stuttering events dropped by 73%, which was the greatest outcome improvement. Distress in speech situations dropped by 44%. Spontaneous speech, taking an oral exam, reading and story retelling to strangers were the most difficult situations, both initially and at the end of treatment. Speaking to the clinician and enumerating were the easiest tasks, again both at the beginning and end of treatment. Stress caused by listener reaction dropped by 22%. The highest level of distress was caused by listener insults, laughter, ridicule and imitation, while clients experienced the least stress when their listeners made positive inquiries.


Advantages and disadvantages


Advantages


An advantage of the CSD treatment is that the method can cover a broad age range of clients since it is suitable for preschool children (from 6.5 to 7 years) to adults.


The CSD multidisciplinary and multidimensional team approach in diagnostics and treatment makes it possible to identify nearly all concomitant stuttering problems and to address stuttering in a holistic fashion. Another advantage is that we combine different treatment formats. A combination of individual and group, as well as residential and outpatient treatment obtain the best outcomes for each client. Each of these treatment formats has a different purpose. The CSD also has rigorous follow-up procedures for the purpose of avoiding relapse or minimising it in case it occurs. Members of the client’s family, their friends, teachers and colleagues are included in the therapy. This has the effect of educating them about stuttering and helps them to see it in a more positive way. They can then be a source of support to the client. Treatment is well structured and easy to apply once a person is familiar with it. Additionally, an advantage of CSD is that no technical equipment is necessary.


Disadvantages


A disadvantage of CSD is that it requires a great deal of commitment from the client, therefore, some do not return after initial diagnostics and some do not complete the treatment (Brajović and Brajović, 1976, 1981). Some drop out after Phase I or during Phase II (Jelčić Jakšić et al., 2003); sometimes they will return several months or years later. The reason for dropouts is that some clients may find the programme too demanding due to its long-term commitment and the effort needed to change themselves. We also find that because speech therapy is covered by health insurance in Serbia, some clients tend to prolong their treatment for longer than is necessary. It is also the case that the treatment relies heavily on individual therapists within the team, which has some disadvantages (Plexico et al., 2010). Finally, we do not have any long-term outcome data for CSD as yet.


Conclusions and future directions


Although the data are from preliminary file audits, there are reasons to believe that the CSD method may be successful in providing a holistic framework for stuttering treatment, based on a holistic view of humans. It is well organised but is also flexible enough to be used for treating a broad spectrum of clients, from preschool children to adults. It combines individual, group, outpatient and residential settings for clients and families, and encourages clients to be their own therapists. The approach has existed for over 40 years and, arguably, has proven its value over that period. We are satisfied with the results so far, but there is always room for improvement and we plan to implement changes to achieve this.


For the future we plan to introduce self-help group into Phase III of the programme with the goal of making clients self-reliant earlier. We also need to improve our treatment gains for stress caused by listener reaction; this dimension currently shows the least improvement of our three reported variables. As a part of the future development of the treatment, we plan to integrate feedback from clients, their families and our colleagues, in the interests of improving the treatment. And finally, we recognise that in the future we need to pay closer attention to evaluating treatment outcomes.


Discussion


Sheena Reilly
The first thing we would like to have is a description of what time tracking is. Our group had about five different definitions of what it might be, so could you tell us what you mean by time tracking?
Jelena Tadić
I never actually defined it, but time tracking is essential if you are going to speak. You need to know how long what you are about to say is, so you can incorporate how much air you need in order to monitor the passing of time while you are speaking. So the video we showed2 was a client who first had the goal of singing correctly for a certain amount of time. When a certain amount of time passed without a clock she had to say how long it was, and ask herself, ‘Could I really do what I planned in that amount of time?’ Because people have the feeling that they have to finish the task and they often speed up. It’s the same for me here, I’m not very good at the moment, I am speeding up, but do I really need to? I can allow myself time to say it slowly.
Sheena Reilly
So you would preset a time for a task and then the client would do the task and then reflect on whether the client allowed enough time. Is that the essence of it?
Jelena Tadić
Yes, I believe it is.
Ann Packman
And to follow up on that, what do you mean by sensory integration?
Jelena Tadić
Throughout therapy, clients are taught gradually to raise awareness and work on development of many aspects of sensory skills, such as listening, voicing, fine motor movements, kinaesthetic feedback, a sense of rhythm and time. This is what is meant by sensory integration. By enhancing their ability to focus on those skills, clients learn to gain control over their speech and react appropriately in speech situations.
Ann Packman
We had some discussion about how your treatments might differ for the very young child compared to the adults. Would you do fluency shaping with young children?
Jelena Tadić
For the very young we do something else. CSD is for preschoolers who are already aware of their stuttering, who already have had some negative experiences with it, who are willing to participate and willing to put in some effort. We make it a bit more fun and of course, we do not engage the reading and writing side of the programme until the children are fluent in reading and writing. What I do notice is that when they start to read, they do not stutter much on reading. When stuttering while reading occurs, that is a good time to incorporate reading exercises, introducing speech exercises into reading, so we are practically following the child’s reading development practically. We also work with parents on their own attitudes towards stuttering and also their attitudes towards their child. Sometimes family therapy is needed to deal with such matters. If the child has additional speech and language problems we will also try to remediate those and to work on them too, maybe not directly on articulation but definitely on the oral motor skills that are helpful, I think, both for articulation and also awareness of articulatory movements. During all this we try to make it fun by telling stories and playing games to engage the children.
Joseph Attanasio
Could we have further clarification on the differences between treatment for adults and the preschoolers? For the preschoolers, is it the goal to eliminate or nearly eliminate the stuttering? Is the goal that the treatment is durable for children? Or as for adults, is vigilance needed to prevent relapse? Would you expect the children to come back when they are adults?
Jelena Tadić
Mostly we don’t expect them to come back and mostly they do not come back if they went through the whole programme. It depends not only on the child but, as I said, on the parents and the family as well. With the Lidcombe Program you also find that the family is very important for maintaining fluency. But, yes, the goal would be to achieve fluency, maybe not perfect fluency but close to it and also to achieve positive attitudes, to help ensure there are no negative feelings about stuttering in either children or parents. If you achieve that, then very often you can see fluency getting better and better in time as they use the recipe for what to do as part of their daily routine. For example, ‘now let’s do a bit of reading’, ‘now let’s do a bit of something else’. That makes it less like therapy and more like just a part of their daily lives.
Sheena Reilly
Do you have criteria for moving from each phase of the treatment to the next?
Jelena Tadić
We do have some general criteria that can be adjusted to individual needs and abilities of the client. Going from Phase I into Phase II we do not expect transfer to other speaking situations. We expect that during Phase III. During Phase I–II we require clients to master the applied techniques for breathing and speech, so they are ready for the Phase III group work. We do not see change dramatically overnight, but then if you allow yourself the time to assimilate it all then there is a high probability of success.
Ann Packman
You said that you would like to gather more data and perhaps do a clinical trial. It is such a comprehensive programme, so what would you consider the primary outcome measures?
Jelena Tadić
The goal of the programme is reduced stuttering together with improved satisfaction in speech situations. Some will drop out of the programme once they feel good and their residual stuttering does not interfere with their life. So we would need both measures of fluency and client satisfaction. We would need separate measures for preschoolers because we would have to include parental attitudes.
Joseph Attanasio
Could you describe or identify the team members and what their responsibilities are?
Jelena Tadić
It is always a speech pathologist and psychologist, and in our institute we have a neurologist, a paediatrician and a physiotherapist. Also, hearing screening is conducted, as well as intellectual testing for all clients. There will also be personality testing if recommended jointly by a psychologist and a speech pathologist. In some cases, clients will need to be referred to a psychiatrist for additional help. The neurologist will also screen for neurological problems that seem to be interfering with the treatment.
Joseph Attanasio
Does every client go through that battery of tests?
Jelena Tadić
Every client, yes.
Sheena Reilly
Can you expand on your relaxation procedures?
Jelena Tadić
It is guided by clients’ Subjective Units of Distress scores from 0 to 100. During relaxation, the first instruction is of course relaxation, followed by imagining a safe place and then from that safe place imagining going into speech situations that you choose. We usually choose a situation to start that has a Subjective Units of Distress score between 40 and 50, because 30 does not interfere really with everyday life. When clients can remain in a relaxed state while imagining the situation, we begin role-play in that situation. After a role-play with the clinician, the client and patient together with the clients will role-play that scenario. And then the rest of group will reflect on what they saw. ‘Were you self-confident or not?’ ‘Okay, you were stuttering but you seemed to be very self-confident’ and so on.
Sheena Reilly
So that is group feedback?
Jelena Tadić
Yes.
Ann Packman
You mentioned bringing the clients consciously back to how they were before they were stuttering. What did you mean by that?
Jelena Tadić
We try to have our clients remember what it was like before they started to stutter. Many of our clients do remember. They may say, ‘I started to stutter when I was five or six or when I started school’. Some normal behaviours and abilities were already developed, because of the normal processes of child development. Bringing them back into conscious memory provides a focus to speak as before.
Joseph Attanasio
How long does this treatment take?
Jelena Tadić
The average treatment time is approximately 12 months, excluding maintenance and follow-up. Not everyone can come for the period of residential treatment because of work and other obligations, and if that is the case then treatment generally takes longer. Perhaps measurement of treatment time is something that we need for our future work.
Ann Packman
It has been obvious over the last few days how much funding determines what treatment we can give. Does your government fund this treatment, or do people have to pay privately?
Jelena Tadić
People usually do not pay privately. There is no charge for those who pay health insurance. However, it appears as if in the future only a specific number of treatment sessions will be available, to cut out the problem I mentioned of clients prolonging treatments unnecessarily
Ann Packman
So does everyone pay health insurance?
Jelena Tadić
Yes, 99% of Serbians.


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1 Although it is not standard practice to publish data at two sources, we felt that it should occur here for the benefit of English speaking readers who otherwise would not have access to data in Serbian language publications.


2 The presenters showed a video of a client demonstrating this time tracking procedure.


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Mar 21, 2017 | Posted by in NEUROLOGY | Comments Off on Conscious Synthesis of Development: A Holistic Approach to Stuttering

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