A recent post to the discussion list for the ASHA Special Interest Group for Fluency Disorders described a teenager who stutters. The question surrounded whether it was the right time for the teen to enter therapy. This sparked some thoughts, because I think this is a really important topic—one that many of us struggle with for school-age kids and adolescents who stutter. When is the right time for therapy?!?
Of course, we’d all like to see teens who need help in therapy, getting support for coming to terms with stuttering and learning to communicate effectively by whatever means are appropriate for them (including speaking strategies and the like). But, all of that will only happen if the teen is ready for it. The question is, what does “ready for it” mean?
I don’t know the answer, but here are some steps I take with my clients when I’m trying to figure out whether to recommend treatment. First, I administer the Overall Assessment of the Speaker's Experience of Stuttering (OASES; Yaruss & Quesal, 2016), or use other measures of impact and quality of life, looking for general guidance about how stuttering is affecting the speaker.
In most cases, there is some adverse impact that would be good to address (again, if the time is right). Still, humans have a tremendous capacity for putting up with problems that are hard to face. This might be viewed in terms of the balance between the pain of change and the pain of staying the same. We might really hate where we are with a given issue, but if addressing that issue is harder, then we will live with the pain and discomfort until it gets so bad that we simply have to do something about it.
So, simply knowing that there is adverse impact from stuttering is not really enough—we have to know how that adverse impact relates to the difficulty the speaker will face in making changes to the speech or emotional or communication difficulties that are causing that adverse impact.
I do this by going through the OASES with my client, one item at a time, and starting a dialogue about how much each one of those specific difficulties is bothering him or her. (For simplicity, I’ll simply say “he” and “him” going forward, given the higher proportion of males who stutter.) So, if he says that he is feeling very frustrated about his speech, then through discussion, we can start to explore whether that frustration is strong enough that he wants to do something about it. (I’m frustrated about a whole lot of things in my life, but I don’t necessarily work on them all the time or all at the same time—my issues have to take a number!) Or, perhaps he indicates that he is having trouble talking freely with his friends. Again, we explore whether that is enough of a burden on him that he’s ready to take some steps to address that trouble.
In my opinion, the next step is crucial: Rather than focusing him on what we’d have to do in therapy in order to make him more fluent or less sensitive or whatever in those specific situations, I first explore what his life would be like if he didn’t experience such frustration, or if he was able to converse with his friends more easily. In other words, we work on establishing a preferred future. (I draw inspiration in this work from Egan’s Skilled Helper model…the too-often overlooked Stage II of the process of change…as well as the concept of living one’s values from ACT, as well as studies of the process of change. Several of our colleagues have done lovely work in our field using these concepts, and I am borrowing liberally.)
We also can then discuss in very honest terms what it would take for the client to be able to reach that preferred outcome—what practice would be necessary, what risks would need to be taken, what challenges might need to be overcome. At this point, though, we can continually frame these hurdles as steps along the path of working toward the desired goal.
By creating an understanding of where the speaker would like to be in his life, we can get a better sense of how to balance the pain of staying the same with the pain of change—and the reduced pain of living in that preferred future. It’s by no means magic, but it can help the client find a motivation for change that comes from working toward that preferred future. He might say, for example, “Yes, I’m in a bad place right now, but I see a future that I’d like to work toward, and it is worth it to me to take steps in that direction.” That is where true motivation can come from.
If on the other hand, he sees where he is and he sees that future and ultimately says, “But really, where I am doesn’t bother me that much…it’s just not worth it for me to face this,” then he might say that the time isn’t right for therapy—but at least he would be doing that recognizing where he is, where he wants to be, and what it might take to help him get there.
For example…perhaps we are evaluating a teen who avoids words and is embarrassed by stuttering (a common situation). Now might very well be the time to make changes in order to reduce his avoidance of words—if the avoidance of words is causing sufficient problem for him, if he’d like to be in a situation where he didn’t do that, and if he sees that he can take the steps necessary to diminish that behavior. It’s not something that we can decide for him, but given the necessary understandings, it is a decision that he can make for himself.
I should say through all of this that parents would of course want the kids to be in therapy, but sometimes wasted therapy—that is, therapy applied when a person isn’t ready for it—can actually do more harm than good. That’s probably a topic for some other post…