Using therapeutic documents - from note taking to note sharing
by Jan Logan

I am a speech and language therapist specialising in dysfluency. I work primarily with groups of people who stammer at City Lit, an adult education institute housing a specialist centre for adult stammering therapy. I have a particular interest in narrative therapy and am currently exploring ways in which these ideas and practices can be usefully transferred to stammering therapy. Narrative therapists are interested in assisting the client in the process of re-authoring preferred or alternative stories of their lives through therapeutic conversations. The approach is collaborative and offers a unique way to assist the person in an exploration of their personal experience of stammering.

In his book 'Living with Stuttering', St Louis (2001) demonstrates how narrative approaches bring a new and broader perspective to stammering therapy. Qualitative research too demonstrates the need for accounts of the "lived experience" of stammering (Crichton-Smith, 2002).

I am currently enrolled on an MSc programme in narrative therapy. The Stammer Trust generously supported my attending the 'Using Therapeutic Documents' module. I would like to share how attending this module has begun to influence my practice as well as how clients have responded to this change.

As a therapist working in education, record keeping is a professional requirement. Notes and reports are usually written after sessions, often for other professionals. Whilst clients have access to the notes and reports I write, records tend to be 'official file' documents, kept to ensure quality and continuity of care through information sharing. Narrative therapists use documents in a different way - 'document making' becomes an integral part of the therapeutic process and is a collaborative project. Notes may be written during a session as a means of capturing the client's words. They are then shared with him/her at the end of the session and the client may take them away if s/he chooses to do so. Some of the ways narrative therapists may use therapeutic documents include:

Documents of knowledge and affirmation
Documents recording achievements/significant change
Documents affirming preferred identities

Therapeutic documents may support revised identities or revised relationships with problems. It is here that I believe these practices have particular relevance for stammering therapy. In my experience, at the end of therapy many people who stammer (PWS) have moved away from the dominant story where stammering has the upper hand, and gained a new relationship with stammering, one that supports easier speech. However, once back in the outside world many slip back into the old story where stammering is experienced as something shameful to be avoided, often at great cost. Therapeutic documents can be used to strengthen the new story.

Since attending the course I have experimented with revising my own note-taking practices. Whilst mindful of professional requirements, I have changed the way I take notes. I now note-share, and this has become part of the therapeutic process. Speedy (2004) suggests therapeutic documents support sessions, capture key moments, thicken emerging stories and remind people about how their stories change over time. With Speedy's comments in mind, I used the notes I took in sessions as a basis for 'between session' letters for a client. The issues highlighted in the letters were discussed at the start of the following session.

A different kind of writing

Demands of work meant the letters were often brief and written quickly, however they also served to document sessions. I was mindful of letter-writing guidelines (Freeman et al., 1997) and the result was a different kind of letter to ones I might have written before the course. I was curious whether receiving the letters and discussing them had made a difference to my client. He reported that they had been "useful" and "very important". He had filed them after reading them more than once. He liked the "personal aspect" and appreciated my thoughts and questions. The letters had provided a "record of the important parts" of our conversations, were a "comparative tool", "a good way of seeing how far I have come" and could help him "take things forward". He added "writing things down" had reinforced his learning and supported change. Interestingly these responses do appear to bear out the points Speedy makes about therapeutic letters supporting face-to-face sessions.

Documents of knowledge

"Documents of knowledge can be extremely useful... in situations where under stress people forget the knowledges and skills that they most need at exactly those times of stress" (Fox, 2003)

This resonated for me in relation to my work with PWS. Following stammering therapy many people report difficulty accessing their newfound skills in challenging situations when under stress. I recently introduced to clients the idea of documenting the particular skills and knowledge they had developed and keeping the document so that it might be available to them following therapy. In fact one client had come to this idea for himself and was keen to keep cards recording his new knowledge/skills in different places in his life such as at work, at home, in the car and so on.

Here is an example of one such document. This document served two purposes, it not only reminded A of the different way he was now dealing with stammering, but made the changes he was making visible to others, reinforcing the increased openness he had been working on and allowing others to lend their support.

This client commented that having the document had indeed assisted him in accessing his new-found skills and attitudes in a number of situations. I wonder if any readers of the present article might find this idea useful?

I have only just begun to integrate these ideas into my work and anticipate developing them further over time. I will be sharing my learning and experiences with colleagues, and hopefully this will bring fresh ideas and approaches to the team and to our student group. I also plan to share my experiences and ideas on the professional training courses (Working with Adults who Stammer) we offer at City Lit and at Fluency Specific Interest Groups in order to promote further discussion around how these ideas and practices might compliment stammering therapy.

References:
Crichton-Smith, I. (2002) Communicating in the real world: accounts from people who stammer. In: Journal of Fluency Disorders, 27 (4) 333-352
Fox, H. (2003) Using therapeutic documents - a review, in International Journal of Narrative Therapy and Community Work 2003 No 2
Freeman, J., Epston, D. & Lobovitz, D. (1997). Playful Approaches to Serious Problems: Narrative therapy with children and their families. New York: Norton.
Speedy, J. (2004). Using therapeutic documents in narrative therapy practices, in Bolton, G., Howlett, S., Lago, C., and Wright, J., (eds.) The Writing Cure: An introductory Handbook of Writing in Counselling and Therapy, Routledge, London.
St Louis, K. (2001) Living with Stuttering. Populore Publishing Company, Morgantown, West Virginia.

Jan Logan is a Specialist Speech & Language Therapist (stammering) at City Lit, an Adult Education Institute in London.

© 2006 Jan Logan

The article is reproduced with the kind permission of the Stammer Trust (www.stammertrust.co.uk). The article appeared in the Stammer Trust Newsletter of Spring 2006.