From client to consultant

Recently City Lit students participated in the training of speech and language therapists wishing to develop their expertise in dysfluency. Jan Logan introduces the perspectives of some of the clients and therapists involved.

At City Lit our approach to therapy is based on the 'partnership' model, placing the client at the centre of the therapy process and acknowledging the expertise on their stammer they bring with them. We are keen to involve students in our speech therapy service, and to this end we invite feedback, contributions from past students on current therapy courses, and have set up a focus group to find out more about what clients want from our service.

"What struck me about the responses of many students was their commitment to 'giving something back'."

We also run a yearly professional training course for speech and language therapists wishing to develop specialist skills in work with adults who stammer. Our aim is to make the course as experiential as possible. Feedback from therapists participating in previous courses identified the need for a more 'hands on' session to support their learning of stammering management strategies.

Responding to this we invited some students, who we felt had a good understanding of stammering management strategies (Block Modification) to be involved in the training. Their brief was to be a 'client' whilst the therapist introduced them to each stammering management strategy by first explaining and then demonstrating it. The therapist then gave feedback to the 'client' on their use of the strategy.

At the end of the session 'clients' gave their therapist feedback on their therapy skills and how it felt to be their client. 'Clients' also included their own explanation and understanding of the particular management strategy and discussed the positives and challenges of using the strategy in the outside world.

We were interested to find out to what extent this had been beneficial, and so asked both students and therapists for feedback - the response was very positive. Feedback from students reminded me of some of the Narrative Therapy literature I have come across which looks at the process clients may go through when working on change, so I thought it might be helpful to share this with readers.

Therapy map

In their book, Experience, Contradiction Narrative & Imagination (1992) Epston & White suggest that the "rite of passage" metaphor can be a useful "map" orienting therapists and clients to the process of therapy. The stages are as follows:

Separation stage - where people are detached from more familiar/taken-for-granted ways of going about things
"Liminal or betwixt and between" stage - often accompanied by confusion and disorganisation but also by a spirit of exploration and heightened sense of possibility
Reincorporation - incorporation of new or resurrected knowledge, brings closure and is often accompanied by new roles, responsibilities and freedoms (van Gennep,1960).

Epston & White go on to suggest that a therapy structured around this metaphor encourages and assists people in negotiating "the passage from novice to veteran, from client to consultant". When people are positioned as consultants to themselves, to others and to therapists, they experience themselves as "more of an authority on their own lives, their problems, and the solution to these problems." Rather than feeling dependent on 'expert' knowledge, clients instead are able to access their own resources and knowledge.

A therapy structured along these lines would, at the reincorporation stage, offer students/clients opportunities to celebrate and acknowledge the new knowledge they have gained in therapy. Involvement in therapist training offered just such an opportunity.

Feedback from therapists indicated that the students offered a valuable contribution to the training, ensuring therapists on the course gained as full an understanding of therapy from the client's perspective as possible. Furthermore, it allowed the students/clients an opportunity to articulate their knowledge and skills and share accounts of struggles they may have had in dealing with stammering or therapy, and any discoveries they may have made which supported their progress.

What struck me about the responses of many students was their commitment to 'giving something back'. It seemed to me that involving clients in this way goes some way towards equalising the power relations between client and therapist. "The relative inequality of 'therapist as helper' and 'client as helped' is redressed. The gift of therapy is balanced by the gift of consultancy" (Epston & White,1992).

Over the years working with people who stammer, my biggest learning has been from the students I work with - our clients are our greatest resource. For us at City Lit it has been a great opportunity to involve them more in our training courses. It is certainly something we are interested in doing more of.

Therapist perspectives:

Fiona Brown: As a newly qualified SLT with limited clinical experience, the opportunity to work directly with a person who stammers was invaluable. I was nervous prior to the session, but it really helped to boost my confidence in my abilities and was perfectly placed at the end of the week long course - I had the chance to practise while everything I had learnt was fresh and it stopped me going away and forgetting things or becoming anxious about my first 'real' session. It was a really powerful and useful way of consolidating the learning.

We were encouraged to practise introducing the techniques and to give and receive feedback to enable us to develop our therapeutic skills. Hearing from someone directly about what you are doing well and what you could change for the better was particularly helpful. I really valued my 'client's' input, I gained more insight into her difficulties as a communicator and she reassured me that she found it helpful to know when she was using the techniques well or if she needed to do something differently. As a result of the session, I will find it much easier to pitch my instructions at an appropriate level and to give honest feedback when I come to teach the techniques. I went away feeling so much more positive about my ability to work effectively with this client group.

Lucia Linfoot: I can see huge benefits directly working with people who stammer; not least the learning process was instantly more meaningful. The student/client's personal feedback gave me and others the opportunity to evaluate and build on our skills instantly. It brought the evidence, techniques and research alive, and experiencing that increased my confidence greatly. The only criticism is that I would have liked more of this opportunity!

Louise Cotton: Training courses these days are a rare luxury, representing for many of us time out from work, an opportunity to network over coffee and engage with knowledgeable experts. The idea of a 'hands on' practical session at the end of a week long course at City Lit seemed a daunting prospect.

For me, like many of the therapists in the group relatively new to working with adults who stammer, the 'a' word (avoidance) so ardently discussed all week seemed a welcome strategy. Questions such as 'what if I exacerbate an individual's stammer?', 'what if I forget bits or don't explain properly?' plagued many of us.

However, in small groups with a willing volunteer student who stammered, we were able to try out these techniques (so good on paper) and learn from each other. Our students obliged, followed instructions and gave encouragement and feedback. Suddenly, the roles were reversed - I was being encouraged by a volunteer student to be my 'therapy self' and to relax. The self-defeat so prominent at the beginning of the session became self-knowledge. We didn't just learn 'how' to do the things on paper; we learnt how it feels for the student. We all took a little something to work on away with us thanks to those who have the biggest insight into how it feels to stammer - thank you City Lit volunteer students.

Client perspectives:

Nicole Eveleigh: As someone that has had therapy in the past and just finished a course of therapy at City Lit - it felt really rewarding to give something back to speech therapists that were mostly learning about adults who stammer for the first time. The feedback I gave them on the teaching techniques was very easy for me to give, but seemed extremely effective for the therapists in helping them progress and fully learn what they had just been taught - which added to the whole process being very enjoyable.

Nicolaas Burgers: One way to look at stammering therapy is to see it as a peculiar teacher-student situation in which the teacher hasn't personally experienced the progression from being a novice to an expert. When one sees therapy from this perspective, as I sometimes do, the idea of the 'teachers' and 'students' collaborating is extremely refreshing and has benefits for everyone. To me, it feels like the different way of interacting helps the therapists gain another dimension to their understanding of what it?s like to have a stammer. As a person who stammers, hearing many therapists explain new and familiar things in a variety of ways can unlock new understanding.

I could almost feel the therapists' repertoires expanding as they communicated and exchanged feedback with each other and the volunteers, and I knew that many people who stammer out there in the world, who are or will be their clients, are going to benefit from us having experienced a workshop set up in this way.

From my perspective I would recommend participating in this kind of session to any speech therapist but I also think people who stammer leave having had more practice and a feeling that they've contributed in a meaningful way to the field.

References:
Epston, D. & White, M. (1992) Experience, Contradiction, Narrative and Imagination, Dulwich Centre Publications, South Australia.
Van Gennep, A. (1960) The Rite of Passage. Chicago; Chicago University Press.

From Speaking Out Summer 2010, pages 16-17