Prior Therapy

Perhaps more than any other communication disorder, clinical failure and relapse appear to be an unfortunate facet of facing those who stutter. The disappointment, frustration, feelings of failure and even anger, among many that stutter can easily be understood.

There are few limits in finding sources of blame for relapse; however, the person who stutters must assume the responsibility for his or her recovery. Some clients come to therapy seeking to be "fixed", rather than understanding that they must actively effect their own fluency. Assuming responsibility for fluency is a fundamental tenet of successful outcomes.

There is a cadre of clients who have not fully overcome the effects of their feelings and emotions about stuttering. Over time, if the feelings and emotions aren't addressed, they will re-emerge and shake the confidence of the speaker, often leading to a return in the frequency of stuttering.

Many people who stutter have become "soured" to the prospects of therapy because of previous unsuccessful clinical encounters or clinicians who were not competent to treat the disorder. Some hold strong feelings of contempt for all speech-language pathologists as a result.

Assessing the attitude of any client is important in understanding their perspective on treatment and learning about their previous attempts in therapy. Ham (1999) discusses some attitudes commonly held by people who stutter. Ham's categories are paraphrased and expanded upon below:

	Perfectionism: Nothing is acceptable but TOTAL fluency. The content of an utterance is of far lesser importance. There is a very strong sensitivity and total rejection of any disfluency, and great discomfort in being in the presence of others who stutter.
	Either/Or: By this "black or white" standard, there is only success or failure with no sense of making progress by lessening or minimizing stuttering. A form of perfectionism.
	Yes, But: A client's superficial agreement with the clinician's perspective, but only a token attempt given to implement suggestions. "I'll try it, but I couldn't do it outside the clinic."
	Prove It: The client offers resistance by requesting proof of ideas and concepts when it is impossible to offer, rather than demonstrate the flexibility to think in new and different ways.
	Been There, Done That: Through past failures in therapy, a client may have become embittered to all therapy. For some, this is a defense mechanism; a protection against the fear of another failure. This type of negative attitude and inflexibility usually results yet another failed attempt in therapy.

The Refresher. Many clients simply need a "refresher course" in the treatment that previous had to regain their skills. Without support after treatment, fluency skills can diminish over time. Clinicians need to be versed in many fluency techniques to be able to substantially replicate the critical elements of a program that had been successful for a client.

There is usually value in "resurrecting" the components of previous therapies that were successful before. If the client had developed effective techniques, that is important information in understanding the nature of their experience with stuttering and determining how to support the efforts in the future.

The Failure. Some clients who had attained fluency harbor strong feelings of failure when their skills diminish and stuttering returns. Their investment of time and money now appears squandered and they have lost something that was important to them. Regaining fluency is usually within fairly easy reach, however the path to reinstating it now eludes them. This client usually needs additional counseling to become better prepared for relapse in the future.

The Disgruntled. An irritated client has little prospect of making any further gains in therapy and is usually quite vocal in not wishing to seek further treatment. Until they are able to see beyond their anger, there is little any clinician can do to assist them. Approaches in treating this type of client should clearly delineate the expectations of the client and clinician, defining the role each will play. Clients should be cautioned that little change can be expected when there is a mindset of failure. A trial period of therapy is often offered to afford a client the opportunity to demonstrate change.

Sincerely Searching. Inside, all people who stutter are seeking relief from their suffering. The vast majority of people who have been in therapy before are looking to make another attempt to overcome their stuttering. There have usually been components of stuttering therapy, which have not been included or incomplete in previous therapies. These often involve overcoming the client's feelings and emotions related to their stuttering.

Clinicians might be well advised to explore with clients the successful and unsuccessful (or incomplete) components of previous therapies. Learning what worked (and what didn't work) and why may make the current therapy attempt more effective and more efficient.

At the conclusion of the first session, the clinician should map out a course of action for the next month, to be used as a trial. This should include a straightforward explanation of the clinician's opinion of the client's prognosis based upon assessment of their attitude, residual skills and responsiveness to therapy techniques during the initial session.

The parameters of change needing to be achieved by the client should be made explicitly clear. The clinician needs to demonstrate an attitude of optimism, blended with realism. Previous therapeutic failure need not be a negative prognostic indicator of future success.

Ham, Richard Clinical Management of Stuttering in Older Children and Adults, Aspen Publications, Gaithersburg. 1999