21/04/2010

1

Intensive Non-avoidance Group Therapy with Adults Stutterers:

Experience from Bulgaria

D. GeorgievaSt. Fibiger

Bulgaria and Denmark

South West University Stuttering Research Centerhttp://usrc.swu.bg

EBP in Bulgaria

In Bulgaria numerous approaches are used totreat stuttering, yet there is a paucity ofempirically based research concerning stutteringtreatment outcomes. ‘‘Evidence-based’’treatments built on well-researched andtreatments, built on well researched andscientifically validated techniques, remainrelatively rare in the field of stuttering and areusually limited to behavioral and fluency shapingapproaches (Boberg & Kully, 1994; Boberg &Kully, 1985; Craig et al., 1996; R. J. Ingham,2003; Onslow, 2003; Bothe, 2004).

EBP in Bulgaria

With increasing emphasis being placed onevidence-based practices in clinical speechlanguage pathology, an objective evaluation ofthe effectiveness of specific stuttering treatmentapproaches in Bulgaria is imperative(Георгиева, 2005).The new paradigm of Evidence-Based Practice(EBP) is unknown to the majority of Bulgarianlogopedists (Георгиева, 2002; Георгиева, 2005;Онслоу, 2004).

21/04/2010

2

EBP in Bulgaria

EBP is a popular concept in otherEuropean Union countries, as well as inthe USA, Australia, and Canada, and isregarded as fundamental to logopedicspractice (Sacket, Rosenberg, Muir-Gray,Haynes, & Richardson, 1996; Ingham,2003; Ingham, & Cordes, 1997). However,appraising EBP is often controversial anddifficult (Langevin & Kully, 2003; Кully &Langevin, 2005).

EBP in Bulgaria

Because of the lack of EBP guidelines inBulgaria in relation to stuttering, it is difficult toprovide:(a) The maximum potential benefits for clients(b) Optimum clinical education and training for(b) Optimum clinical education and training forlogopedics students and practicing speechlanguage pathologists(c) More cost-effective practice(d) Knowledge about difficult or unusual cases influency disorders(e) Better treatment for each individual stutterer.

EBP in Bulgaria

The failure to make clinical practice evidence-based means Bulgarian logopedists:(a) May fail to recognize the needs, abilities,values, preferences, and interests of individualsand their families to whom they provide clinicaland their families to whom they provide clinicalservices(b) May not acquire and maintain the knowledgeand skills necessary to provide high qualityprofessional services, including knowledge andskills related to EBP

EBP in Bulgaria

(c) May improperly evaluate prevention,screening, diagnostic procedures, protocols, andother measures used to identify maximallyinformative and cost-effective diagnostic andscreening tools(d) May fail to evaluate the efficacy,

effectiveness, and efficiency of clinical protocolsfor prevention, treatment, and enhancementusing criteria recognized in the EBP literature inthe leading countries in that area.

Health system for stutterers in Bulgaria

Many publications, both in Bulgaria andabroad, point out that the Bulgarian healthsystem does not offer any kind oflogopedics therapy for adults who stutterlogopedics therapy for adults who stutter(Георгиева, 2000; Georgieva, 1995;Fibiger, Peters, Neumann, 2006; Fibiger,Peters, Neumann, Biain de Touzet, 2008).

MethodsParticipants

Seven stutterers (6 males and 1 female) wererecruited from two consecutive sessions of thegroup intensive therapy offered at The SouthWest University Stuttering Research Center inBlagoevgrad.These 7 individuals were all of the participantsenrolled in the 6 days intensive sessions. Allparticipants volunteered to be part of the studyand provided written informed consent.

21/04/2010

3

MethodsParticipants

The 7 participants were all nativeBulgarian speakers as well as being fluentin English.They came from three different BulgarianThey came from three different Bulgariancities: Sofia, Blagoevgrad, and Varna.The mean participant age was 22.8 years(range = 14–29).

MethodsParticipants

All the participants had experiencedfluency shaping therapy prior to thecurrent intensive stuttering modificationtherapy (averaging 12 6 years prior to thetherapy (averaging 12.6 years prior to thepresent study; range = 4–23). Oneparticipant had stuttering modificationtherapy (1 year prior to participation in theSWU course).

Assessments of the multidimensional disorder

The primary goal of this study was to assesstreatment outcomes using a variety ofmeasurements of stuttering, including:( ) t t tt i t ( t tt i(a) overt stuttering measurements (stutteringfrequency and scores on the Stuttering SeverityInstrument for Children and Adults, Third Edition[SSI–3]; Riley, 1994), and(b) client perceived stuttering measures(WASSP), (Ayre & Wright, 2000).

Assessments of the multidimensional disorder

Evaluation of stuttering severity in wasbased on stuttering frequency during oralreading and spontaneous speaking.The series mentioned above consists ofThe series mentioned above consists oftwo fluency and affective-basedmeasurements, which were assessedbefore treatment and immediately aftertreatment.

SSI – 3 results

S1 - point 39 (99%)S2 - point 22 (52%)S3 - point 26 (42%)S4 - point 29 (59%)

Very severe Moderate Moderate ModerateS4 - point 29 (59%)

S5 - point 43 (99%)S6 - point 33 (80%)S7 - point 23 (30%)

ModerateVery severe Severe Mild

WASSP

WASSP reflects the belief that success instuttering therapy cannot be measured by areduction of dysfluency alone, but needs toconsider the changes in a range of factors.Specifically it measures changes in the four keySpecifically, it measures changes in the four keyareas of stuttering:BehaviorCognitionAffectParticipation.

21/04/2010

4

WASSP

WASSP reflects the social dimensions ofstuttering and is related to the WorldHealth Organization’s InternationalClassification of Impairments, Disabilityand Handicap (ICIDH; WHO; 1980), (Ayre& Wright, 2009).One of the first studies on the relevance ofthe ICF for dysfluent people was done byYaruss, 2007.

WASSP

The ICF is becoming increasinglyimportant as a framework for assessingand describing different types ofcommunication disorderscommunication disorders.WASSP has been used in 18 countries(including Bulgaria) located in sixcontinents.

Audio/Video-Recording Procedure and Speech Material

Speaking samples were collectedimmediately pre and post treatment.Each participant was audio- and video-recorded during an oral reading task (‘‘Therecorded during an oral reading task ( TheSWU history passage’’) and during aspontaneous monologue-speaking task.

Audio/Video-Recording Procedure and Speech Material

For the spontaneous speaking task, participantswere informed that they should speak for at least4 minutes at a normal rate and loudness.Topics could relate to work and their interests.pA minimum of 200 words were collected foreach participant.The audio and video signals were collectedusing a Sony digital video camera.

Audio/Video-Recording Procedure and Speech Material

The camera was situated approximately2.5 meters from each participant andpositioned to obtain a clear video image ofthe participantthe participant

Speech Sample Analysis

The video recordings of each participant’sspeech were later viewed on a Sony TV monitor.To improve analysis accuracy and reliability, ap y y ywritten transcript of the monologue-speakingtask was created for all participants. Whole wordrepetitions and interjections were transcribed,but otherwise no coding of stuttering type wasmade on the original transcripts.

21/04/2010

5

Speech Sample Analysis

A second clinician (Andreeva) counted the actualnumber of stuttered words by marking them on themonologue transcripts and copies of the readingpassage.Frequency of stuttering was calculated for each sample

th b f d t tt d di id d b th t t las the number of words stuttered divided by the totalnumber of words spoken.Words were coded as stuttered if they contained anytype of repeated movement (whole syllable repetitions,incomplete syllable repetitions, or multisyllable unitrepetitions) or any type of fixed articulatory posture (withor without audible airflow).

Speech Sample Analysis

Each word was coded as stuttered onlyonce, regardless of the number of differenttypes of stuttering present within the word.Interjections such as ‘‘ah’’ or ‘‘um’’ werenot counted or analyzed.Secondary features and average durationsof the three longest moments of stutteringwere calculated using the SSI–3guidelines (Riley, 1994).

Therapy approach

The design of the therapy program waskindly elaborated by Dr. Fibiger and wasbased on the application of the VanRiper’s (1973) stuttering modificationRiper s (1973) stuttering modificationapproach.Usually, the Bulgarian logopedists preferto apply fluency shaping approach and aremuch more familiar with it.

Therapy approach

Therapy was conducted within theStuttering Research Center at South WestUniversity in Blagoevgrad, and transferpractice took place in nearby publicpractice took place in nearby publicsettings such as shopping malls.Group and individual therapy was offeredfor six hours (10-13 AM and 14-17 PM)during the weekdays.

Therapy approach

Clients were assigned numerous speaking tasksto complete during the mornings.The program was directed by a certified speech-language pathologist (Steen Fibiger fromDenmark), who had received training in) gadministration of the non-avoidance approach inSweden and Denmark.He has also been a fellow at the Charles VanRiper Language, Speech and Hearing Clinic atWestern Michigan University.Dr. Fibiger also served as a consultant for theUniversity Stuttering Research Center.

Therapy approach

The other three Bulgarian clinicians involved in the therapy course were: Dr. Dobrinka Georgieva, trained at Northwestern University’s stuttering modification approach workshop, pand two assistant professors in Logopedics working from SWU – M. Simonska and Anna Andreeva (both are certified speech-language pathologists). D. Georgieva, S. Fibiger, and M. Simonska have each written a Ph.D. dissertation on stuttering.

21/04/2010

6

Therapy approach

Each client was assigned two clinicians,who were enrolled in this stutteringworkshop.The present non avoidance therapyThe present non-avoidance therapyintensive course was the first one in thecountry conducted for adult stutterers.

Therapy Program

Day One: Information is givenconcerning the goals of the therapyprogram (Van Riper’s story).Initial testing (self rating) using WASSPInitial testing (self-rating) using WASSPis carried out, and issues of motivationand identification are addressed.

Goals of the Therapy Program

to learn how to handle interruptions in the flow of speechfrom tensed and struggled blocks to a slow, easy andsoft stutteringto reduce negative feelings and desensitize the emotionsdue to reactions from the environmentdue to reactions from the environmentto learn new courses of actions in relation to speech andcommunicationto learn how to be your own stuttering therapist and to beactive and responsible for changing your stutteringbehavior to more fluent stutteringto improve the understanding of each individual patient’sstuttering by video recording.

Motivation for this therapy approach:

The stutterer needs to assess her/his motivationfor seeking therapy and the logopedic toolsrequired for building and maintaining themotivation necessary for successfully changingspeech behaviours and attitudes Facing one’sspeech behaviours and attitudes. Facing one sweaknesses squarely enough and long enoughto change them is not easy. Stuttering therapy isnot something to enter into lightly; it takes alarge investment of time, physical energy,emotional energy, and money.Motivation is addressed throughout the therapy.

Identification of stuttering behaviors:

In the identification stage, the client and clinicianidentify all the behaviours, feelings, and attitudesassociated with the person’s stuttering.First the client is taught how to identify primaryg y p ybehaviors, secondary behaviors, and feelingsand attitudes that characterize the client'sstuttering.Observation of prolongations, repetitions, blocks,avoiding behaviors etc. are noted.

Day Two:

Desensitization is conducted in three stages:First the client has to accept that he/shestutters.Next the client has to hold or continue theNext the client has to hold or continue thestutter; the goal is to make the client lessemotional and more tolerant of the stutters.The last part of desensitization is when the clientvoluntarily stutters.

21/04/2010

7

Day Two:

This helps the client remain calm when astutter happens.Voluntary stuttering is when the personstutters on purpose By choosing whenstutters on purpose. By choosing whenand how to stutter, the individual begins togain control over the stuttering and thefear and anxiety begin to diminish.

Day Three:

Variation/Modification is followed byapproximation with the three strategiesfor altering stuttering:CancellationCancellationPull-outPreparatory set.

Day Three:

Stuttering Modification emphasizes howto change difficult stutters into easier moremanageable stutters.You can start with selecting one of yourYou can start with selecting one of yourown ways of stuttering:

Day Three:

Cancellation, in which the person stuttersall the way through a word, stopsimmediately, and then repeats the wordstuttered a different waystuttered a different way.Pull-out, in which the person gains controlover a moment of stuttering while it ishappening and smooth it out, and

Day Three:

Preparatory set, in which the personprepares for a moment of stuttering beforeit happens, starts it gently and glidesthrough it smoothlythrough it smoothly.Strategies such as bouncing, sliding, easyonset, and light contacts representvariations on these three techniques.

Day Four:

Assimilation involves training in the newfluency modification techniques andmodeling different speech situations and isessential part of the therapyessential part of the therapy.

21/04/2010

8

Day Five:

Stabilization includes the transfer of the newspeech techniques into real day situations(under a speech language pathologist’s control).Therapy evaluation and final self-rating withWASSP profile, as well final observations anddirections about the future intervention andtherapy are the accent of the work.The stabilization part of the therapy has to becontinued over a long period of time in order tostabilize the new stuttering behaviors.

Results - WASSPS individual profile

WASSPS Summary Profile None very severe

Galja 1 2 3 4 5 6 7

1 Frequency of stutters 2 1 Physical struggle during

stutters 2 1 Duration of stutters 2 1 Uncontrollable stutters 2 1 Urgency/fast speech rate 2 1 Associated/facial body

movements 2 1 General level of physical

tension 2 1 Loss of eye contact 2 1

Beha

viou

rs

Other (describe) 2 1 Negative thoughts before 1 Negative thoughts before

speaking 2 1 Negative thoughts during

speaking 2 1 Th

ough

ts

Negative thoughts after speaking 2

1 Frustration 2 1 Embarrassment 2 1 Fear 2 1 Anger 2 1 Helplessness 2 1

Feel

ings

Other (describe) 2 1 Of words 2 1 Of situations 2 1 Of talking about stuttering

with others 2 1 A

void

ance

Of admitting your problem to yourself 2

1 At home 2 1 Socially 2 1 Educationally 2 1 D

isadv

ant

age

At work 2

Results - WASSPS individual profile Results - WASSPS individual profile

Results - WASSPS individual profile Results - WASSPS individual profile

21/04/2010

9

Results - WASSPS individual profile Results - WASSPS individual profile

Discussion

In addition to a stuttering frequency score, thetotal overall SSI–3 score includes the stutteringmoment duration score and a physicalconcomitants score.Given that stuttering frequency decreasesfollowing treatment, it is likely that decreases instuttering moment duration and decreases insecondary features contributed most to thesignificant lowering of overall SSI–3 scores.

Discussion

In this regard, two of the central goals of thepresent therapy relate to eliminating concomitant(secondary) behaviors and decreasing theseverity of stuttering moments when they occur.Based on the cursory assessment of stutteringBased on the cursory assessment of stutteringduration and concomitant behaviors provided bythe SSI–3, it appears that the therapy may havebeen successful in reducing stuttering severityimmediately following treatment.However, this improvement was not maintainedover the long term.

Discussion

The set of 5th subscale of the WASSPrevealed the considerable positivechanges in response to participation in thecourse in one out of six of the participantscourse in one out of six of the participants.A small change after therapy wasobserved in only in one case (S6, pdf table6).

S6

Eleven of the examinees’ WASSP profileparameters were not changed after theintensive course. We may explain this factby the inability of the patient to admit theseverity of stuttering, as well as feelingsand avoidance at the beginning of thecourse and as a final result.The client was not motivated from thebeginning of the therapy.

21/04/2010

10

S6

He reports positive change and awareness of the parameters:frequency of stutters h i l t l d i t tt iphysical struggle during stuttering

uncontrollable stutters negative thoughts before speakingembarrassment

S6

anger avoidance of situations and to talk about stuttering with others di d t d t t tt i i ll ddisadvantage due to stuttering socially and educationally

S6

The initial completion of the WASSPprofile showed the client had highexpectations “to reduce and to eliminatecompletely my stuttering”completely my stuttering .

S6

In the time two profiles he wrote: “During thisblock I understood that I talk faster than Ithought. I also saw during the visual exercisesthat I do some facial movements especiallyblinking with my eyes The techniques weblinking with my eyes. The techniques weworked on I found to be not very useful for mebecause I consider myself a less severestuttering case. Probably the technique can beuseful for me is the pull-out. I don’t use it veryoften but if I focus on working with the pull-outtechnique it might work out for me”.

Others

The rest of the clients reported a visiblechange of progress in approximately allfive subscales of the WASSPTheir explanatory comments in the lastTheir explanatory comments in the lastsection of the profile reveal they haddeveloped accurate reflection on thestuttering outcomes

Suggestions for Future Therapy

This study represents only an initial step inobjectively evaluating the outcomes obtaining byintensive group therapy for adults.The present results are relevant only to anp yintensive group treatment format.While the non-avoidance approach is a classicexample of a stuttering modification approach tostuttering therapy, it is only one variant of manystuttering modification treatments.

21/04/2010

11

Suggestions for Future Therapy

It is not known whether these results canbe generalized to other stutteringmodification approachesThe absence of a non treatment controlThe absence of a non-treatment controlgroup, or an alternative treatment, alsomakes it difficult to place the presentresults in a larger context.

Conclusions

The present study represents the firstWASSP’s evaluation of a stutteringmodification treatment program – nonavoidance approach in Bulgaria.The goals presented in the beginning ofthe paper, e.g. to reduce avoidancebehavior, anticipation, and social andcognitive anxiety through desensitizationto stuttering were reached.

Conclusions

The five subscales of the WASSPrevealed the considerable positivechanges in response to participation in thecourse in 90% of the participantscourse in 90% of the participants

Conclusions

Although reduced frequency of stuttering wasnot an overt goal of our intensive therapy, somemodest improvements in stuttering severity wereobserved immediately following treatment.However, these improvements were short-lived.We strongly believe that without further long-term data (i.e., greater than six months posttreatment), even the durability of the changesoutlined above is questionable.

Conclusions

The practice of evidence-based stutteringtherapy requires that clinicians apply the mosteffective, proven, and efficacious techniquesavailable (Onslow, 2003).In summary, the non-avoidance intensive grouptherapy outcomes presented here providequalified support for some changes in affectivefunctioning but negligible improvements in corestuttering behaviors and secondary behaviors.

Conclusions

Our first experience showed that WASSP isbriefer and easy to administrate.It is useful as an assessment and outcomemeasure in the intensive stuttering therapy.We can report that the present version of theWe can report that the present version of theintensive group modification program achievedshort-term improvement.This program is useful for adults exhibiting apersistent stuttering disorder that have failed toshow substantial improvement from othertherapy methods.

21/04/2010

12

Contact us: doby_logo@abv.bg