Review of the Successful Stuttering Management Program

Given the paucity of evidence to support the clinical effectiveness of the SSMP, a recent attempt was made to evaluate the SSMP on various treatment outcomes (Blomgren et al., 2005). Blomgren et al. (2005) independently evaluated the SSMP when it was offered at the University of Utah from 1999 to 2002. Specifically, a series of 14 fluency- and affective-based measures were used to assess the SSMP immediately after treatment and 6 months after treatment. Measures included (1) stuttering frequency, (2) the Stuttering Severity Instrument (SSI; Riley, 1994), (3) a self-rating of stuttering severity, (4) the Perceptions of Stuttering Inventory (Woolf, 1967), (5) the Locus of Control of Behaviour scale (Craig et al., 1984), (6) the Beck Depression Inventory (Beck and Steer, 1993), (7) the Multi-component Anxiety Inventory IV (Schalling et al., 1973) and (8) the State-Trait Anxiety Inventory (Spielberger et al., 1983). Results of this study indicated that the SSMP appeared to reduce a number of anxiety related features of stuttering, such as self-perceived avoidance and expectancy of stuttering, and self-reported psychic and somatic anxiety. Further, these anxiolytic reductions appeared to be durable, as measured 6 months post-treatment. However, the results also indicated that no durable reductions were identified in (1) decreasing overt stuttering frequency, (2) decreasing stuttering severity (measured as a composite of stuttering frequency, stuttering moment durations and secondary behaviours (SSI-3)), (3) self-assessed stuttering severity, (4) self-assessed perception of struggle to speak, (5) self-assessed amount of muscular tension, (6) self-assessed improvement in mood, (7) self-assessed improvements in locus of control or (8) self-assessed improvements in state or trait anxiety. Based on these findings, the SSMP was deemed to be an ineffective treatment for decreasing stuttering and related muscular struggle behaviours, but it was deemed to be an effective treatment for decreasing some of the anxiolytic and avoidance aspects of stuttering. This conclusion is justified by the possibility that a non-randomised outcomes study may lead to overestimation of any effect sizes compared to the gold standard of a randomised control trial (Kunz and Oxman, 1998). Figure 8.1 summarises the results of the Blomgren et al. (2005) clinical trial.

Advantages and disadvantages

Advantages

The programme addresses the acceptance, disclosure and perception of stigma that many people who stutter find difficult. Additionally, the intensity of the treatment, the group dynamic and the ‘it’s OK to stutter’ philosophy are positive aspects for many participants. From a historical perspective, the programme was developed with input from those who stutter. It is probably not inconsequential that Breitenfeldt is a person who stutters, as were Johnson, Van Riper and Sheehan. From an evidence-based perspective, the SSMP does appear to decrease avoidance and expectancy of stuttering as well as some forms of anxiety (Blomgren et al., 2005).

There are a number of possible weaknesses of the SSMP. The 3-week intensive nature of the treatment is cost and time prohibitive for many people who stutter. The treatment is also very dependent on the stuttering management counselling skills of the clinicians, which may influence the portability of the approach across clinicians. In this sense, the ‘therapist effect’ may play a larger role in stuttering management therapies than in more regimented speech restructuring approaches (Crits-Cristoph et al., 1991).

Disadvantages

The main weakness of the SSMP for many stuttering speakers may simply be that decreasing stuttering frequency is not a goal of the treatment. As such, the approach does not teach fluency-facilitating techniques and subsequently the programme does not result in decreased stuttering frequency or decreased struggle to speak (Blomgren et al., 2005). For many stuttering speakers, the singular focus on treating the anxiolytic and reactive aspects of stuttering might be viewed as insufficient – especially in light of the many available programmes that report positive results in decreasing core stuttering behaviours (Andrews et al., 1980; Blomgren, 2010; Howie et al., 1981; Ingham, 1975; Kroll and Scott-Sulsky, 2010; Kully et al., 2007; Montgomery, 2006; O’Brian et al., 2010; Ryan, 1974).

Conclusions and future directions

Stuttering management therapies, including the SSMP, are based on procedures directed at desensitisation to stuttering, increasing acceptance of stuttering and motoric techniques to decrease the muscular tension associated with stuttering moments. The approaches may also include CBT. In this respect, stuttering management therapy tends to be primarily anxiolytic in emphasis (Blomgren et al., 2005).

Published treatment outcomes of the SSMP indicate that the approach does not treat stuttered speech, but rather the acceptance, avoidance, stigmatic, and anxiolytic symptoms of the stuttering disorder (Blomgren et al., 2005). Two broader conclusions from the Blomgren et al. (2005) study may be proposed. First, stuttering frequency does not appear to ‘automatically’ decrease in response to reductions in self-reported anxiety. In other words, decreasing anxiety alone is not sufficient to decrease stuttering frequency. However, it does appear possible to decrease anxiety related to stuttering – even in the absence of any actual decrease in stuttering frequency.

In summary, the anxiolytic aspects of stuttering do appear to be treatable, even in the absence of related decreases in stuttering frequency and severity. The positive aspects of the SSMP are in helping people who stutter manage their fears, anxieties and avoidances related to stuttering and speaking. However, it may be argued that for any stuttering treatment to be considered ‘successful’ the treatment should reduce stuttering frequency as well as any participation or activity restrictions (Finn et al., 2005; Yaruss, 2001; Yaruss and Quesal, 2004). Therefore, combining techniques from the SSMP with fluency shaping or speech restructuring therapies will likely result in the most extensive positive treatment outcomes.

Through research, stuttering treatment has advanced significantly over the past decade. The new standard for stuttering treatment is using combinations of treatment approaches that address overt stuttering as well as the avoidance, affective, self-perceptive and anxiolytic aspects of the disorder. However, determining the most effective combination of speech restructuring and stuttering management techniques for each stuttering speaker will likely depend on the abilities, needs and wants of the individual clients themselves. New developments in computer-aided biofeedback (Kroll and Scott-Sulsky, 2010), pharmacological treatments (Maguire et al., 2010) and self-modelling (Bray and Kehle, 1998; Prins and Ingham, 2009), combined with effective treatment maintenance strategies may also add significantly to therapy success. Identifying the essential aspects of the SSMP and perhaps combining them with other established and evidence-based treatments may lead to improved treatments all round (Blomgren, 2010).

Discussion

Joseph Attanasio
Thanks for your clear overview that provoked lots of discussion in our group. The first question I’d like to start with is why do you think this is the most common and most popular in the United States? It doesn’t reduce stuttering, as you’ve shown. It does have obviously some impact on anxiety and some other dimensions related to anxiety, but couldn’t that be achieved by other approaches such as CBT? It seems paradoxical.
Michael Blomgren
That’s a very good question and of course the answer to that would just be my opinion. In the United States, not many speech pathologists use speech restructuring techniques (see Preface for a definition of this term). I would venture to say the majority of speech-language pathologists in the United States focus on stuttering management techniques. This is due to both history and the fact that the major textbooks in the United States tend to have a stuttering management emphasis to them. Also the Stuttering Foundation of America is an influential organisation that emphasises on stuttering modification.
Sheena Reilly
Your presentation prompted a lot of discussion and interest in our group as well. We were interested in what clients expect when they come to the programme.
Michael Blomgren
Generally I don’t think treatment programmes advertise their intended outcomes very well. I’ve seen clients where I think they were expecting something quite different than what they received and that is a problem. However, I would guess that most clients come to the SSMP aware of what it’s about. I would say most do their research before and know about the programme in advance. For the clients that don’t know about the SSMP, it might be a bit of a rude awakening on Day 1 where they need to go out and advertise that they stutter in public. The SSMP doesn’t practice systematic desensitisation; it is more like a sink or swim approach.
Joseph Attanasio
We’d like you to clarify the anxiety component here. Did you say that anxiety was reduced? Your data seemed to show that state and trait anxiety did not change.
Michael Blomgren
There wasn’t a decrease with the State-Trait Anxiety Inventory but we did measure a significant post-treatment reduction for scores on the psychic anxiety and somatic anxiety subscales of the Multi-component Anxiety Inventory. We also measured a significant reduction of avoidance behaviour on the Perceptions of Stuttering Inventory. I view a reduction of avoidance behaviour to be related to anxiety.
Ann Packman
You talked about trying to identify which components of the programme might be more effective than others. Could you tell us what you think they might be? And if you were to change the design of SSMP, what changes would you make?
Michael Blomgren
The SSMP is not my programme, so any suggestions for change are purely academic. I think the dose issue is important and is currently an unknown factor. I am not sure that clients need 3 weeks to learn the SSMP techniques, so changes to the overall duration might be possible. From both a personal and a clinical perspective, I think one of the most powerful SSMP techniques is disclosure. With a little practice most clients who stutter can get into the habit of disclosing their stuttering, so I would want to emphasise that. The pseudo-stuttering technique, involving stuttering on purpose, is difficult to sell to clients. They often say, ‘I came here to learn to not stutter and you’re saying, “stutter more”?’ So maybe the pseudo-stuttering is not as important as disclosure. The stuttering modification techniques of prolongations and pullouts can be very helpful in giving clients some skills to control the intensity of stuttering moments. My opinion is that too little time is devoted to practicing those techniques.
Sheena Reilly
We were interested in the result that there was no post-treatment move towards internal locus of control when so many of the procedures are designed to give clients control over their stuttering. Can you comment on that?
Michael Blomgren
Perhaps locus of control only changes when there is a corollary change in stuttering severity and/or perception of decreased struggle associated with stuttering. We didn’t see changes in those areas in the SSMP so perhaps that is why we also didn’t see post-treatment movement towards more internal locus of control. We are just completing a treatment outcome study of a comprehensive stuttering clinic that included prolonged speech techniques. We had 29 clients and we did measure a statistically significant change in locus of control (Blomgren et al., 2009). In this study, we also had a statistically significant decrease in frequency of stuttering. So perhaps decreased stuttering is necessary for a feeling of increased internal locus of control.
Joseph Attanasio
You measured changes in stuttering and recorded that stuttering frequency did not change. However, the programme helps clients modify the moment of stuttering, so what were the changes there? Were they successful in actually modifying the moment of stuttering for the better?
Michael Blomgren
That is an important question, but one for which I don’t have a direct answer. We didn’t specifically assess any qualitative aspects of stuttering moments, such as average duration, or amount of struggle. That is something that could certainly be done. In fact, it should be done in any future study. We have some indirect data related to your question from the scores on the SSI. The SSI provides an overall score that is based on a combination of stuttering frequency, the three longest moments of stuttering and an assessment of secondary stuttering behaviours. So, in a sense, the SSI captures some additional aspects of stuttering beyond simple frequency counts. The SSI scores did decrease significantly immediately after the treatment but the decreases were not evident 6 months later. I think a more detailed examination of how clients might be modifying moments of stuttering would be prudent.
Ann Packman
We had an interesting discussion about measuring the amount of everyday speaking. Some of your measures were to do with reading and monologues and did not tap into that. But we also discussed that, in relation to avoidance, couldn’t clients reduce avoidance simply by speaking less at the end of the programme? We were interested in whether there had been any measures done on those aspects in relation to this programme?
Michael Blomgren
No.
Ann Packman
Do you think it’s possible?
Michael Blomgren
Yes, it is possible, but probably somewhat difficult. One way of measuring avoidance might be to measure amount of speaking time. This could be done with a voice dosimeter. A voice dosimeter measures the speaking time per day and has been used with voice-disordered speakers. This could be an excellent real life outcome measure of stuttering treatment. I don’t believe it has been used before with people who stutter.
Sheena Reilly
Our group was also interested about the satisfaction levels associated with the programme: client satisfaction of course, but also student satisfaction because it is conducted in a university clinic. How do you inform students about other treatment options for clients?
Michael Blomgren
I believe that students should receive training in a broad range of treatment options. The SSMP was offered at the University of Utah from 1998 to 2001. Our current intensive stuttering clinic is a comprehensive clinic, which replaced the SSMP in 2002. The current clinic is based on a combination of prolonged speech training and stuttering management techniques. Unfortunately, I think most university programmes in the United States teach stuttering management to the exclusion of anything else.
Sheena Reilly
That would be an innately self-reinforcing cycle favouring stuttering modification?
Michael Blomgren
Exactly.
Joseph Attanasio
You mentioned that the programme depends upon the counselling skills of the clinician. With the programme administered by students, what do they do? What does a typical day look like in terms of what students are doing with clients?
Michael Blomgren
In the SSMP, the daily routines are quite regimented. There is a 170-page manual that the clients work through. The manual has daily activities and generally the clients spend about half an hour in a group session and then meet with their individual student clinician for about half an hour. The day progresses between group and individual sessions. Any new technique is presented in the group setting by the master clinician. The student clinicians then reinforce these techniques during individual sessions. In reality, the student clinicians are often learning the programme techniques at nearly the same time as the clients. With respect to the point about counselling, I believe many counselling issues are related to problem solving. For example, when working on disclosure a client might say, ‘I’m not going to do that’ or ‘I can’t do that’. Perhaps counselling might go along the lines of asking, ‘Well, why do you think you can’t do it?’ or ‘Exactly what would you be willing to do?’ Some student clinicians get the hang of it right away and others struggle with it. As with all student supervision, it is ultimately incumbent on the clinical supervisors to help both the clients and the student clinicians acquire these skills.
Ann Packman
We wondered whether you think the programme in its current form is sustainable. The current tough economic climate1 for people in the United States must make it difficult for clients to afford programmes like this. Considering that, and that evidence about its long-term effectiveness is limited, is SSMP viable?
Michael Blomgren
The programme has been conducted at Eastern Washington University since 1962, so history suggests it is sustainable there. On the other hand, I don’t believe it is currently being offered anywhere else. The high costs associated with intensive programmes such as the SSMP do limit the amount of people that are able to attend.
Sheena Reilly
Do you have any details about clients that did better or were more satisfied with their outcomes? For example, were older clients more satisfied or clients who had, say, a speech restructuring treatment previously and then feel the need for an anxiolytic treatment?
Michael Blomgren
Participants in the SSMP have varied from young adolescents to clients in there seventies. There were clients without previous treatment history and those who had received extensive speech treatment previously. I’m not aware of any research examining these variables. Anecdotally, though, I think if a client is outgoing and willing and able to talk about their stuttering, they will likely do well in an approach such as SSMP. But I guess it’s the ‘avoiders’ who need this type of treatment the most.
Joseph Attanasio
A statistical question for you. Your data analyses were repeated t-tests. Can we assume that these analyses contained some sort of corrections to protect against Type I errors?
Michael Blomgren
Yes, we did an adjustment procedure so the requisite significance level was small. That said, there are good arguments that it is unnecessary to make alpha adjustments in outcomes studies such as this because most measures are independent of one another. There is always a trade-off between Type I and Type II errors.
Ann Packman
We also had a discussion of what link there might be between programmes like this one, which focus on desensitisation about stuttering, and the support that people get in it by just being together, and the kind of benefits that arise from self-help groups. Could you speak a bit about what the link might be between the two?
Michael Blomgren
I think there are similarities and overlap between desensitisation programmes like the SSMP and support groups. In both cases, the process of being open to discussing stuttering and approaching speaking situations is paramount. In order for someone to even contemplate attending a self-help group, I think that there needs to be a certain level of acceptance. Acceptance of stuttering and desensitisation to stuttering are obviously linked. Indeed, clients are encouraged to join a self-help group after treatment.

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1 Just prior to the symposium, a global financial crisis had emanated from the United States and severely impacted the country.

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