Student-Delivered Treatment for Stuttering: Multiday Intensive Speech Restructuring

To demonstrate the adaptability of a student education clinical model, a modification of the Camperdown Program (O’Brian et al., 2003) (see Chapter 2) was designed to fit into that model at La Trobe (Cocomazzo et al., 2011). The adapted model involved 26 weeks of treatment during 10 weeks by 24 student clinicians. There were two, 2-hour individual teaching sessions followed by one 8-hour group practice day. This was followed by seven 2-hour problem-solving sessions. Twelve adults undertook the programme: 10 men and two women, with a mean age of 29 years and a range of 21–47 years. Outcomes were reported pre-treatment, immediately post-treatment and 12 months post-treatment by means of within-clinic recordings with a clinician and beyond-clinic recordings with familiar people. Again, the La Trobe student education model produced benchmark outcomes. %SS beyond the clinic was 5.5 pre-treatment and 1.2 and 2.1 immediately post-treatment and 12 months post-treatment, respectively. Speech naturalness analyses provided essentially similar results to Block et al. (2005).

Advantages and disadvantages

Advantages

A significant advantage of speech restructuring treatments such as those outlined previously is that people who stutter can quickly learn strategies to speak fluently. Importantly, large numbers of clients can be treated simultaneously. They experience massed practice opportunities to change their speech motor pattern. While participating in intensive treatment when others with the same problem attend at the same time, there are frequent opportunities to meet and practise with others struggling with the same issues: they experience support and camaraderie from others in the group. This can provide opportunities for education, support and desensitisation. Intensive treatment allows for much change during a short period. This in itself can be strongly motivating for an individual who has grappled with stuttering over many years.

From an academic and clinical perspective, students experience all aspects of the treatment process. They experience both assessment and all stages of the treatment process: fluency instatement, transfer, maintenance and the virtually inevitable need to deal with relapse. One of the most important advantages of these clinical placement experiences is that students have access to supervisors who are specialists in stuttering treatment. Indeed, participants in the Block et al. (2005) and Cocomazzo et al. (2011) trials reported enjoyment working with enthusiastic, well-prepared and well-trained students and knowledgeable clinical supervisors.

Disadvantages

Of course, rapid change from intensive speech restructuring can bring disappointment in the common event of relapse. Thus, it is important that on-going maintenance opportunities are available. This is particularly the case considering that one report has identified the presence of mental health disorders – most of which involve anxiety – determiners of whether a client will be in the two-thirds of cohorts who typically experience problems with fluency maintenance (Iverach et al., 2009). Clearly then, for some, speech restructuring alone may not be sufficient to overcome the sense of handicap that can ensue from a lifetime of stuttering (Bloodstein, 1995). As a consequence, additional and different treatment such as adjunct treatment with cognitive behaviour therapy may be appropriate (e.g. see Menzies et al., 2008).

Providing students with adequate clinical experience with stuttering is expensive and time-consuming. Clinic experiences such as those outlined previously require dedicated and experienced clinical supervisors. The need for on-going feedback, report reading and marking are onerous for the staff involved. There is a large workload for clinical supervisors. Sufficient and flexible space is required to accommodate a service delivery model such as La Trobe, where there might be up to 16 clients, 32 students and four supervisors present simultaneously. The clinic sessions are long, the work is repetitive and the supervision is expensive. In spite of these issues the learning experiences for the students are sufficiently valuable that they report them to be an enjoyable experience leading to confidence working with people who stutter.

Some challenges with student-delivered treatment for stuttering relate to limited and potentially decreasing funding, increasing student numbers, increasing demand for clinical services and pressure from university administrators to divert staff time from clinical supervision to research activity. However, as shown with the reports outlined here, integrating research and clinical experience is one means of achieving that goal.

Conclusions and future directions

The clinical services outlined previously demonstrate that large numbers of students, well supervised, can provide an effective clinical service for large numbers of adolescents and adults who stutter. They can achieve positive speech outcomes for their clients. They can impact their client’s well-being and quality of life. A flexible and varied service delivery has provided a range of valuable experiences for both clients and students. Students embrace these experiences enthusiastically. Based at least on the reports reviewed here, it is evident that people who stutter will come to university clinics for treatment. Because research is a significant part of university life, clients are usually very happy to participate in a variety of research programmes. Such programmes can be integrated into a student-delivered clinical service with impressive speech outcomes. They also provide valuable experiences for students to enhance what they will do when they enter the workforce following graduation. They also provide valuable clinical experiences that may help students feel positive and confident about treating people who stutter.

The future challenge here is to encourage researchers to be involved in student education so that students can contribute to meaningful clinical research about the evidence-based treatments they will use during their careers. To ensure this, sufficient funding needs to be provided to ensure the careful integration of research, clinical service delivery and adequate clinical supervision. Researchers in such settings can motivate students with their expert research knowledge and clinical experience. We plan to continue a close association with researchers to collaborate on alternative treatments and service delivery options. Additionally, we are investigating ways of increasing student numbers in each clinical placement, to ensure that clinical supervisors are not overburdened and clients experience adequate continuity of care.

There is a need to make treatments for adults more accessible and as simple as possible. With regards to the former, telehealth service delivery of speech restructuring treatment is an option that is becoming more readily available and more comprehensively researched (see Chapter 10). A recent randomised controlled trial (Carey et al., 2010), conducted at the La Trobe clinic, showed this service delivery model to be equivalent to in-clinic treatment in terms of outcome. Consequently, we are incorporating telephone and webcam sessions where clients are unable to attend all sessions in the clinic. This should ensure more flexible treatment options for people who find it difficult to access treatment or to access on-going treatment. We anticipate involvement in future clinical trials of this method. With regards to treatment simplicity, the CP was developed in part to address that issue, and we anticipate participation in further clinical trials to supplement the Cocomazzo et al. (2011) report described previously.

Discussion

Joseph Attanasio
You generated many questions in our group about student training, which is something that involves many of us. Could you talk about how the students who do the therapy are trained? How they are selected and how they are supervised?
Susan Block
I present their stuttering management course during their third year, so I know exactly what they have been taught. The course is approximately 50 hours of class time. We have people who stutter coming in to talk to the students about their experience of stuttering and their experience of treatment. As part of their course they are required to go to a self-help group meeting without me or any other staff member being present, so they can discover first hand what those who stutter say about their experiences and the treatment they have received. Part of their assessment during their course is real time measurement of %SS, which is a core clinical skill for the treatments described. Their training occurs with a computer-based speech-rating package (Block and Dacakis, 2002). Additionally, they are familiar with self-rating scales such as those used with the CP. They have a 1-hour group meeting with their supervisors before the intensive programme. During that meeting they are given an outline of the programme and details of what they will be expected to do, and they have to prepare some resources. For example, the programme begins with a list of isolated consonants and vowels, and then various vowel–consonant combinations for clients to practise with the requisite speech pattern before they attempt connected speech. They prepare those lists themselves and the intention there is to have them start thinking about the processes of the programme. Then on each morning of the programme we meet with them for about 1 hour of briefing before the clients arrive. For that meeting we expect them to bring ideas and resources with them. So, for adolescents they might need to bring games and literature and things that might interest an adolescent. Supervisors, of course, watch the students working and give them real time guidance, but also students receive written feedback each day. It is critical for the students to model the speech pattern correctly for the clients, so supervisors are particularly vigilant to ensure that they do that correctly.
Ann Packman
Could you comment on something we discussed? If this symposium is any kind of guide, there are an extraordinary number of different treatments available. So you are in a no-win situation as a clinical educator. You can expose students to a range of treatments, with clinical mastery of none or have students attain professional entry-level competence in one treatment only. It just does not seem feasible for students to attain competence in more than one stuttering treatment, considering all the other speech and language disorders they have to treat. You clearly have gone down the path of seeking student clinical competence in one adult treatment only.
Susan Block
Of course during my coursework students are introduced to a wide range of treatments. But I could defend our training in one specific treatment style for students on the grounds that speech restructuring and its variants has by far the best clinical trials evidence to support it than any other adult treatment.
Sheena Reilly
You strike us as a master clinician and educator. There is no doubt what happens at your university clinic is remarkable. But we wondered whether it could be replicated. Could any of us do what you have done, or is it your charisma and strong professional motivation that is the key to your success.
Susan Block
It’s a really important point because Bloodstein’s (1995) well-known criteria for evaluating treatment include that the treatment has to be shown to be effective in the hands of essentially any qualified clinician. And of course students are not qualified clinicians, and I think it is important that our students can achieve results as favourable as any reported in the clinical trials literature. But to answer your question directly, the programme has been replicated as a student training clinic at the University of Sydney and at the University of Queensland.
Joseph Attanasio
You described two student clinicians per client. Could you tells us why and what the impact might be on the clients and the clinicians, and if the student clinicians give feedback to each other?
Susan Block
We do it in pairs to deal with the student numbers. A benefit of working with student pairs is that they can learn from each other. However, I constantly make the point that two student clinicians do not equal one qualified clinician. Of course, it would be much easier to work with one student per client, but that would halve the numbers of students to whom we could provide clinical education, and cause us not to meet our target of proper clinical education for them. I should say that from the client point of view, working with a pair is of students is sometimes much better than working with one, and sometimes it’s the other way around. Students vary of course with skill level, so during the programme we rotate them among the clients.
Ann Packman
Just to clarify, are you saying that every La Trobe speech pathology student obtains experience in your intensive group programme?
Susan Block
No, they did once but no longer, which is something I have never become comfortable with. All our masters students do the programme and probably about 60% of the undergraduates.1 The majority of the undergraduates who don’t do a clinical placement with the intensive programme do one with the Lidcombe Program. However, every student who requests a stuttering placement will get one, even if we need to take extra clients to manage the numbers. If they do not have a requested stuttering placement at La Trobe, we subsequently attempt to obtain one for them at some other time during their course, in a community clinic.
Sheena Reilly
We had a discussion about how the skill of an individual clinician can mediate an outcome for a client. How do you ensure quality control with your programme, given that, as you said, that not all students have equal skills?
Susan Block
A colleague who is very experienced and works in the clinic with us all the time occasionally will say that clients get better despite the students because the treatment is so powerful. But quality control is of course an issue. We have audio-visual recording facilities in the clinic, and if a student needs some feedback about clinical errors with clients we often record and play back the errors and discuss them. At the end of each lunch break, we meet with the students and go over the strengths and weaknesses with what we have seen them doing. Many of those interactions involve discussions about common student errors with counselling, such as not following through with client leads and terminating discussions prematurely.
Joseph Attanasio
You obviously have integrated research effort into your student clinical training programme. Could you divulge the secret about how you’ve been able to do this? It’s been my experience at least that it’s very difficult to convince students and their supervisors to do research. Their primary effort is to help that client and that does not leave room for much else.
Susan Block
The answer is simple. We accomplish it by means of a large group of researchers who share the load of the research, who are spread across several Australian cities. All these people contribute to the work of conceptualising, doing and writing up research. Most of the clinical trials of speech restructuring treatment in Australia have pooled participants from many clinical sites, the majority of which involve student supervision.
Ann Packman
I understand you have some anxiolytic procedures in your programme. How do the students deal with that? Is that more difficult for them to master than the speech restructuring procedures?
Susan Block
It is a little more difficult for them. A core skill for them to acquire is construction of a desensitisation hierarchy for clients, and that is far from straightforward. However, generally during the treatment anxiolytic procedures are closely linked with speech restructuring procedures so the clinical training of them is manageable during the programme. One challenge is to stop students who are interested in psychology going off on a tangent and losing the essential focus on speech restructuring. All the anxiolytic procedures we use are designed to facilitate that programme goal.

References

Andrews, G., Guitar, B., & Howie, P. (1980) Meta-analysis of the effects of stuttering treatment. Journal of Speech and Hearing Disorders, 45, 287–307.

Andrews, G., Craig, A., Feyer, A., Hoddinott, S., Howie, P., & Neilson, M. (1983) Stuttering: A review of research findings and theories circa 1982. Journal of Speech and Hearing Disorders, 48, 226–246.

Block, S., & Dacakis, G. (2002) Stuttering counts. Measuring stuttering and speech rate. Multimedia Production Unit, COMET, La Trobe University, Melbourne, Australia.

Block, S., Onslow, M., Packman, A., Gray, B., & Dacakis, G. (2005) Treatment of chronic stuttering: outcomes from a student training model. International Journal of Language and Communication Disorders, 40, 455–466.

Bloodstein, O. (1995) A Handbook on Stuttering (5th ed.). San Diego, CA: Singular Publishing Group.

Boberg, E. (1981) Maintenance of Fluency. New York: Elsevier.

Boberg, E., & Kully, D. (1994) Long-term results of an intensive treatment program for adults and adolescents who stutter. Journal of Speech and Hearing Research, 37, 1050–1059.

Carey, B., O’Brian, S., Onslow, M., Block, S., Jones, M., & Packman, A. (2010) Randomised controlled non-inferiority trial of a telehealth treatment for chronic stuttering: The Camperdown Program. International Journal of Language and Communication Disorders, 45, 108–120.

Cocomazzo, N., Block, S., Carey, B., O’Brian, S., Onslow, M., Packman, A., & Iverach, L. (2011) Camperdown Program for adults who stutter: A student training clinic Phase I trial. Manuscript in preparation.

Cream, A., O’Brian, S., Jones, M., Block, S. Harrison, E., Lincoln, M., et al. (2010) Randomized controlled trial of video self-modelling following speech restructuring treatment for stuttering. Journal of Speech, Language, and Hearing Research, 53, 1–11.

Goldiamond, I. (1965) Stuttering and fluency as manipulatable operant response classes. In: L. Krasner & L. Ullmann (Eds.), Research in Behaviour Modification (pp. 106–156). New York: Holt, Rinehart and Winston.

Ingham, R. J. (1984) Stuttering and Behavior Therapy. Current Status and Experimental Foundations. San Diego, CA: College-Hill Press.

Iverach, L., Jones, M., O’Brian, S., Block, S., Lincoln, M., Harrison, E., & Onslow, M. (2009) The relationship between mental health disorders, stuttering severity and treatment outcome among adults who stutter. Journal of Fluency Disorders, 34, 29–43.

Kelly, E. M., Martin, J. S., Baker, K. E., Rivera, N. I., Bishop, J. E., Kriziske, C. B., & Stealy, J. M. (1997) Academic and clinical preparation and practices of school speech-language pathologists with people who stutter. Language, Speech and Hearing Services in Schools, 28, 195–212.

Martin, R., & Siegel, G. (1966) The effects of simultaneously punishing stuttering and rewarding fluency. Journal of Speech and Hearing Research, 9, 466–475.

Menzies, R., O’Brian, S. Onslow, M., Packman, A., St Clare, T. & Block, S. (2008) An experimental clinical trial of a cognitive behavior therapy package for chronic stuttering. Journal of Speech, Language, and Hearing Research, 51, 1451–1464.

O’Brian, S., Cream, A., Onslow, M., & Packman, A. (2001) A replicable, non-programmed, instrument-free method for the control of stuttering with prolonged speech. Asia Pacific Journal of Speech, Language and Hearing, 6, 91–96.

O’Brian, S., Onslow, M., Cream, A., & Packman, A. (2003) The Camperdown Program: Outcomes of a new prolonged-speech treatment model. Journal of Speech, Language, and Hearing Disorders, 46, 933–946.

Packman, A., Onslow, M., Webber, M., Harrison, E., Lees, S., Bridgman, K., & Carey, B. (2011) The Lidcombe Program of Early Stuttering Intervention. Treatment Guide. Retrieved from http://sydney.edu.au/health_sciences/asrc/docs/lidcombe_program_guide_2011.pdf

Reilly, S., Onslow, M., Packman, A., Wake, M., Bavin, E. L., Prior, M., & Ukoumunne, O. (2009) Predicting stuttering onset by the age of 3 years: a prospective, community cohort study. Pediatrics, 123(1), 270–277.

Shames, G., & Sherrick, C. (1963) A discussion of nonfluency and stuttering as operant behavior. Journal of Speech and Hearing Disorders, 28, 3–18.

Speech Pathology Australia. (2001) Competency-Based Occupational Standards (CBOS) for Speech Pathologists – Entry Level. The Speech Pathology Association of Australia Limited, Melbourne. Retrieved from http://www.speechpathologyaustralia.org.au/resources/compassr

St. Louis, K. O., & Durrenberger, C. H. (1993) What communication disorders do experienced clinicians prefer to manage? ASHA, 35, 23–27.

Yaruss, J. S. (1999) Current status of academic and clinical education in fluency disorders at ASHA-accredited training programs. Journal of Fluency Disorders, 24, 169–183.

Yaruss, J. S., & Quesal, R. W. (2002) Academic and clinical education in fluency disorders: an update. Journal of Fluency Disorders, 27, 43–63.

1 At the time of the symposium, the La Trobe School of Human Sciences conducted undergraduate and postgraduate speech pathology programmes.

Only gold members can continue reading. Log In or Register to continue