An Australian experience
Stuttering Therapy DownUnder
By Isobel Crichton-Smith

However politically correct I think I am, I still find myself confronted by my own personal stereotypes on a regular basis. For example, if you had asked me about Australia fifteen years ago I may have said something like 'Neighbours', 'cricket' and 'Surfers Paradise'. Later on when I became a speech and language therapist I realised that there was more to Australia than teenage soap operas and leisure pursuits. Furthermore, two years ago when I began working as a researcher for the Dominic Barker Trust I would have been able to say a whole sentence on the matter, along the lines of "Hmm, Australia...home of the Lidcombe Programme: controversial treatment for early stammering." It was at this point in time when it became evident to me that Australia was one of the countries at the forefront of research into stuttering and yet their ideas sometimes seemed to be at odds with the UK. Fortunately, I was given the opportunity to spend the best part of last November in Australia and now, I can manage a whole article.

The Australian Stuttering Research Centre

The team at ASRC

I initially spent time with Professor Mark Onslow and his team at the Australian Stuttering Research Centre (ASRC) based at the University of Sydney. The ASRC comprises of researchers and therapists who are dedicated to the development, validation and dissemination of the research that they carry out into stuttering. The ASRC is 'home' of the Lidcombe Programme, a behavioural treatment for young children who stutter, which began life over ten years ago and is now accepted as an effective treatment both nationally and internationally. In addition to their work on the Lidcombe Programme, the ASRC clinicians, based in specialised clinics throughout Sydney, provide therapy for all other age groups. As Lidcombe therapy has been shown to be effective with children up to the age of 12, older children usually receive this as a first line strategy, however there are children for whom this treatment is not enough and then other therapies need to be instated such as smooth speech.

The ASRC are also interested in the way that therapy is delivered to adults who stutter. If they are seen at one of the ASRC clinics these adults are usually taught prolonged speech. Prolonged speech comprises of various features such as extended vowels and continuous voicing and it is, they believe, one of the best practice methods for the control of stuttering. However, they are concerned because there is no guarantee that any two therapists will teach the same procedure. To this end they are currently experimenting with the use of a standard video of prolonged speech for the adults to imitate. This allows the individual to take whatever component they feel is necessary from the speech pattern they hear to promote fluent speech and eliminates the need for therapists to decide on what features would best facilitate fluency for clients. A large part of this programme, following instatement of natural sounding speech, is maintenance of fluency. The therapist and client meet regularly to review progress and to problem solve on how to maintain acceptable levels of fluent speech in everyday settings. A key component of this therapy is to identify a supportive person who is used throughout therapy to monitor practice and to provide feedback.

Working with 9-14 year olds

Ashely Craig and Gillian Carmichael

Further research into the treatment and development of stuttering is being undertaken at the Department of Health Sciences, University of Technology, Sydney. This research is led by Professor Ashley Craig who is perhaps best known for his work with Gavin Andrews on 'locus of control' but as a clinical psychologist by profession, his other interests lie in pain management, anxiety and behavioural techniques for treating stuttering. Professor Craig and his team have recently focused on the treatments available for 9-14 year olds - a largely neglected age group in current stuttering research. They looked at the efficacy of three types of therapy: an intensive smooth speech programme, a smooth speech home based programme and a programme to reduce muscular tension using computerised electromyographic biofeedback (EMG). EMG involves attaching sensors to the face that monitor the electrical impulses produced by the muscles, this is linked to a computerised display, which indicates the level of muscular tension. Through exercises and games the children are taught to control the level of tension in their facial muscles as it is through the reduction of muscular tension that stuttering is also reduced. It was found that all three methods were successful in reducing dysfluency but that a significant 30% suffered relapse 12 months post treatment. An investigation of this relapse showed a link between pre-treatment stuttering severity and maintenance of fluency, from these results they suggested that perhaps some children would benefit from more or less therapeutic input relative to their pre-treatment stuttering severity.

Gillian Carmichael, a PhD student, is investigating stuttering at a neurophysiological level. She is researching the differences between the neurological activity in children who stutter and controls using electroencephalography (EEG), which is a non-invasive and safe way to examine electrical impulses produced by the brain. This is an important venture as current published neurophysiological research indicating different loci of brain activity between people who stutter and controls, focused solely on adults. Gillian?s research will address the issue of whether such neurophysiological differences are developmental or acquired.

Smooth speech for adolescents and adults

Susan Block

To complete my visit I spent time with Susan Block, a senior lecturer at La Trobe University, Victoria. Susan teaches the fluency component of the speech pathology degree at the university and runs a fluency clinic for adolescents and adults who stutter. The courses they run comprise of a weeks intensive introduction to smooth speech and 7 weekly follow up sessions. Like many other Australian stuttering programmes there is a strong emphasis on transfer of fluent speech from the outset of the course. Participants are strongly encouraged to record their speech at home, identify friends and family to practice with in face-to-face and telephone situations, and are sent out of the clinic to familiarise themselves with the use of the new speech pattern in public places.

Final Thoughts

The therapy for stuttering I observed was quite evidently influenced by a different philosophy than in other countries. The programmes provided for children who stutter often contained elements of behaviourist techniques such as rewards for fluent speech. 'Speak more fluently' techniques such as 'smooth' and 'prolonged speech', are also provided as a matter of course. The treatments I observed were much more focused on the establishment and transfer of fluent speech, than treatments in the UK where intensive programmes strongly emphasise the continuous use of new speech patterns on a 'use it or lose it' basis. I anticipated that this may be the case and was concerned that such an approach may not adequately address wider communication issues or consider the processes involved in change. This could ultimately lead to unrealistically high expectations for some clients. I was, however, impressed by the way that experienced therapists had developed these 'speak more fluently' approaches to incorporate, sensitive and practical ways of being fluent on a daily basis. The tracking of therapeutic progress with taped samples of home practice and the mechanisms for successful transfer of fluent speech out of the clinical environment have been well developed. In addition, the use of family and friends as a starting place for transfer and a support network, seem logical and practical. It is without doubt that like other therapeutic approaches, smooth and prolonged speech may suit some people who stutter more than others, yet the clients I met were satisfied with the aims of their therapy and were happy to be experiencing new levels of fluency in their speech.

My visit to Australia has taught me many things. As a therapist trained in the UK there are fundamental differences in the way that the Australians approach the treatment of stuttering, yet there are also many similarities. I believe that lessons can be learned from working the Australian way - as many UK therapists using the Lidcombe Programme will have discovered. Their aim to provide a good quality service to clients through the pursuit of effective, replicable treatments is paramount and to this end, Australia will continue to be an extremely influential force in the field of stuttering.

On a more personal note, visiting Australia has taught me the value of 'experience', I will now rely less on what other people say and my own stereotypic gut reactions and make more of an effort to find out for myself 'how things really are'.

This trip was funded by BT and the Dominic Barker Trust, I am indebted to them and to the researchers and therapists in Australia for making my visit possible.

Isobel Crichton-Smith, MSc
Research Fellow
Dominic Barker Trust
Suffolk College
Ipswich
Suffolk
IP4 1LT
01473 296 344
Isobel@pghas.demon.co.uk

From the Winter 2000/2001 issue of 'Speaking Out'