Counseling People Who Stutter and Their Families*

Stuttering, like many complex human conditions and behaviors, results from a complex interaction of a number of innate and environmental factors. One of the challenges for speech-language pathologists who work with people who stutter is to delineate the specific features that contribute to the different stages in stuttering development; that is, the emergence of stuttering in young children, the persistence of or recovery from stuttering in this same population, and the nature of the disorder in children and adults with chronic stuttering problems. For most children and adults who stutter, these factors include the speech behaviors that characterize stuttering (e.g., sound and syllable repetitions and sound prolongations), as well as the thoughts and emotions that develop in reaction to the experience of stuttering. For families, especially the parents of children who stutter, coping with their emotions and reactions to the child or adult who stutters is often a key issue. It is this piece of the stuttering puzzle--the thoughts, beliefs and emotions surrounding stuttering--that are the focus of the counseling process in treatment.

In general, counseling can be viewed as a helping relationship in which the clinician, or counselor, guides the individual toward finding "their own answers, to experience an internal sense of control, and to leave with new perspectives and the confidence that they can care for themselves (Riley, 2002)." In the case of people who stutter and their families, the counseling process should lead to the realization that there are possibilities for thinking and doing something different. Instead of the "musts" or "must nots," the "cant's" and "cans," the "shoulds" and "should nots," that so often characterize the individual's and family's response to stuttering, a new, broader perspective emerges in which options are recognized. This, according to Luterman (2001) should be the goal of counseling; the forging of a relationship that is based on the assumption that people can make themselves happy, but in some cases might benefit from a counselor who can help them recognize their inherent ability to make good decisions for themselves. For many speech-language pathologists, this may seem like a tall order, one that is beyond their training and experience. In actuality, it is easier than it appears if we change our concept of what it means to counsel.

According to Luterman (2001), speech-language pathologists and audiologists have historically viewed counseling as "informing and persuading." At the end of an evaluation in which the presenting complaint is "stuttering," we inform parents that their child does (or does not) stutter, and if he does, we describe options for treatment and in general recommend (i.e., persuade) them to follow the one we think will be most beneficial. In our report, we detail the results of our assessment protocol and invariably state that we "counseled" the parents concerning test results and therapy choices. In our therapy records, we describe "counseling" sessions that consist mainly of discussing treatment progress and homework assignments. Luterman suggests a third approach to counseling our clients, one that is rooted in a process of listening and valuing their stories, thoughts, emotions, and concerns. Through listening and valuing, we assume that clients and their families are competent to solve their problems without our explicit instructions. We assume that they already have everything they need, that they already possess the "basic wealth" to discover the way through to acceptance or change (Chodron, 2001). Contrary to the medical model that forms the basis of our profession (i.e., find the disorder and "fix it" or at least treat the symptoms), through listening and valuing alone we assume that in fact nothing needs to be fixed, that the client and family are the experts about their own lives and are the best suited to help themselves.

For many speech-language pathologists, this perspective seems inadequate to accomplish our responsibilities. It is true that we have to provide information to the client and family about stuttering, and it is also true that one of our central professional responsibilities is to provide some level of treatment, whether through direct service or referral. However, it is just as true that in almost every case, the client and family experience an emotional response to receiving the news that their stuttering is chronic and will require effort to change, or that a child is not typically disfluent, but is stuttering and is not likely to outgrow the problem. Their emotional responses will be very individualistic, and will run the gamut from guilt, shame and fear, to anger and in some cases, rage. These emotions and the behaviors they trigger may be directed inward, as in the case of the adult who stutters who has denied for years the presence of stuttering and its global impact on his life. Or in the case of parents of a young child who stutters, who blame themselves for the problem. It can also be directed outward, toward the family members who are blamed for an individual's stuttering (by the person who stutters), or toward the parents who believe that the child can stop stuttering "if he wanted to."

Regardless, emotional responses to stuttering and its often life-changing influence cannot be underestimated or ignored by the clinician. They are at the core of the client's coping strategy both adaptive and maladaptive. It is emotion--what the client and family do both consciously and unconsciously to cope with and adjust to the problem (Beck, 1995) -not rational thought, that most strongly influences behavior. The clinical significance is that without helping the client and family to uncover the way they feel about the problem, and how these emotions contribute to their actions, it really doesn't matter what therapy road we persuade them to follow; they will not be fully on board. What we advise and suggest will be less powerful than what the client and family feel in determining their actions.