Dan Hudock, Ph.D., CCC-SLP, a person who stutters himself, is an Associate Professor of Communication Sciences and Disorders at Idaho State University. He is also the Speech Language Pathology Graduate Program Co-Director, PhD in Rehabilitation and Communication Sciences Program Founding Co-Coordinator, and Founding Director of the Northwest Center for Fluency Disorders that offers a two-week interprofessional intensive stuttering clinic (NWCFD-IISC) with Speech Language Pathologists collaboratively working with Counselors and Psychologists to treat adolescent and adult clients who stutter through Acceptance and Commitment Therapy (ACT). His areas of research include psycho-emotional-social aspects of fluency disorders, interprofessional collaborations with mental health professionals, and the neuroscience of speech perception and production in people who stutter using high-density EEG. Dr. Hudock has received various funding to support his research, clinical endeavors, and educational outreaches. He has over 30 peer-reviewed publications, 80 international through local presentations with several recent ones being invited keynote and full day talks, and one TEDx Talk entitled “Please don’t finish my sentence” about the experience of living with a communication disorder. Note: You should consult with your doctor or speech pathologist for recommendations on treatment. The views and opinions expressed in this article are those of Dr. Hudock and do not necessarily reflect the official policy or position of SpeechPathologyMastersPrograms.com How did you become interested in holistic stuttering therapy? I’ve stuttered for as long as I can remember talking, most of my life very severely (nearly 20-40% of the words I said often with blocks up to several minutes long per word). I attended speech therapy from pre-school throughout graduate school with varying results, but a constant from those experiences was the compassion I felt from the Speech Language Pathologists (SLPs). Another point that kept me coming back was the sense of connection. Although some of my SLPs initially stated that I was the first “stutterer” that they saw and that they didn’t know much about stuttering, I believed that their training and experience had them poised to understand me more than anyone else in my life. I often felt like my SLPs were the only ones who truly understood me and the experiences I had being someone who stutters, despite the fact that they openly disclosed a lack of knowledge on the topic or that we did not openly or directly talk about my experiences with stuttering. They showed me compassion and holding onto that belief of being understood, which may sound a bit nonsensical especially given that many of my family members stutter: my brother, mom, grandma, and some great uncles (from what I’ve been told). It wasn’t until much later in my life that I actually was given, and took, the opportunity to talk about my experiences with stuttering and connect with others who I felt like understood me and my experiences with stuttering. We didn’t talk about the experience of stuttering, or the psycho-emotional-social impacts it caused, in my family, with my friends, at school, or with an SLP, although it was the omnipresent elephant in the room. Later in elementary school the SLP had other kids who stutter on her caseload, so we would occasionally get together in our small group of kids who stutter. We again didn’t openly or directly talk about our shared experiences with stuttering and instead mainly focused on our techniques in casual conversation, but being there with them, seeing how stuttering affected them (and being very naïve to the impact I experienced from stuttering in my state of self-preservation, survival) and hearing that they didn’t have friends because of their stuttering was very impactful for me. This is what motivated my desire to become a SLP and to helps others who stutter by showing them that our stuttering does not have to hold us back. I engaged more in social interactions, did more activities, and pushed myself towards extroversion. In hindsight I believe that I was trying to overcompensate for the vast sense of inadequacy I felt because of stuttering and prove that I was almost as good as fluent speakers (but not quite as good). This seminal experience helped me connect to the experience of stuttering, interestingly through others rather than connecting to it through my own experiences. Nearly all of the stuttering therapy I received from preschool through the start of my graduate program was primarily focused on trying to make me a fluent speaker, which further exacerbated my feelings of shame, guilt, resentment, failure, anxiety, and depression. Why could I not meet the expectation that others had set for me? Why would I be able to control my stuttering in the therapy room, but then be woefully unable to control it out of therapy, where it actually mattered? These emotions and thoughts resided within me, but were very seldom discussed. So I, as many people who stutter (PWS) do, knew something was missing from therapy, that major factors weren’t being addressed, but since the SLPs weren’t bringing it up I felt like I wasn’t supposed to either. That this was just the therapy process and that I was wrong for feeling like there should have been more. Then being around more PWS through the National Stuttering Association, clinical interactions, and being mentored by someone who stutters in graduate school I started to catch glimpses of other possibilities that might be in regard to my stuttering, how I thought about my stuttering, etc. I knew these were important aspects, but not until I started working at Idaho State University in 2012, by happenstance at the same time as a new faculty member from the Department of Counseling, did I start to see the potential for a formalized structure for how this interprofessional holistic approach to stuttering therapy might look. Discussions with that faculty member and continued evolving discussions with other faculty members from the Department of Counseling have clarified this vision and practice for me. Now having had these experiences with both personal and professional growth and seeing the many benefits to clients and clinicians alike from taking a holistic approach, I can’t see not taking a holistic approach with clients who have chronic communication disorders. Which types of stuttering therapy are considered holistic and which are non-holistic? What are the advantages of a holistic approach? The traditional approaches to stuttering therapy have historically been Stuttering Modification and Fluency Shaping. Stuttering Modification seeks to improve one’s attitudes and beliefs about stuttering and help them become more effective at managing their stuttering, knowing that stuttering will still be present, but may become less disruptive. Stuttering Modification follows Identification, Desensitization, Modification, and Generalization sequences. First we as professionals seek to increase awareness about stuttering behaviors, attitudes, and beliefs. Then we try to desensitize our clients to fear and negative emotions, attitudes, and behavioral practices we’ve adopted into our speech. We then try to further modify behaviors, attitudes, and beliefs and lastly work toward stabilizing some of the changes that have occurred. Fluency Shaping in contradiction is based in learning theory and behaviorism – trying to create fluent speech and fluent speakers. The hope here is that PWS can be taught a new form of controlled speech that if used 100% of the time should make them fluent and should become their new form of speech. A problem here is that at some level speech does have innate mechanisms and changing how we talk will never truly become a new form of adopted speech. Decades of research also demonstrates that when fluency is the primary goal of stuttering therapy it has resoundingly negative impacts on the individual (higher reported anxiety, senses of failure, guilt, shame, resentment, and depression, increased reported suicidal ideation etc), whereas openness and acceptance are frequently reported as being the most successful goals of therapy and what PWS report the focus should be on, typically resulting in better, longer-lasting, positive outcomes. From a technical perspective, either or both of these philosophically different paradigms could or could not be considered holistic. Holistic refers to an understanding that the parts of a system are interconnected and can only be fully explained with the whole in mind. For example, it is my belief that stuttering is a multidimensional syndrome due to the psychological, emotional, social, motor, and linguistic factors that influence it. This labeling of a multidimensional syndrome is supported by the Diagnostic Statistical Manual (DSM), frequently used to characterize diagnosable conditions, definition of stuttering or the World Health Organization’s International Classification of Functioning, Disability, and Health (WHO-ICF). Both present influence of the personalized experience of stuttering and the associated psycho-emotional-social impacts as contributing to the disorder. Some of the recent professional shift of the American Speech-Language and Hearing Association (ASHA) and SLPs to more holistic approaches for stuttering therapy have also been influenced from the Overall Assessment of the Speaker’s Experience of Stuttering (OASES) (Yaruss & Quesal, 2004) that is based on the WHO-ICF. If a clinician is open to a client’s personalized lived experiences with their communication disorder across multiple psychological, emotional, social and many other domains and focuses therapy on treating deficits / impacts within those domains from an interactionist perspective they will likely be taking a holistic approach. The client’s lived experiences must be of paramount importance and focusing on the client first (before the symptoms that they present) create the atmosphere for a holistic approach. As depicted earlier, when fluency is the primary goal of stuttering therapy it consistently results in instilling negative impacts and have very high rates of relapse. When a holistic approach is taken more positive, longer-lasting, outcomes are consistently reported with higher quality, more supported, experiences reported throughout therapy. Holistic approaches allow people to feel more connected, to be more supported in their growth, challenge themselves to push their growth edges, and to be part of a higher quality experience. When approaching speech therapy more holistically we better understand the interconnected processes at play and can take a more active role and responsibility in the experience. We start to see our values more clearly, make decisions that align to our values, and gain a depth of understanding our thoughts, emotions, and actions. We’re challenged to go deeper to better understand ourselves, our emotions, motives, rationales, and decisions. In other words, by taking a holistic approach we connect more congruently to ourselves and to others, and develop a clearer understanding of the underlying aspects and how the affect each other in the decisions we make. In your TedX Talk, you mention that stuttering is like an iceberg, where only 10% of what it entails is above the surface- can you explain to our readers what you mean by this? The disruptions that occur; blocking, repeating sounds, or holding sounds out in prolongations, and secondary stuttering behaviors (e.g., blinking, finger / hand / foot / leg tapping, extremity movements) that we use to try to reduce stuttering or increase fluency are the observable, overt, features of stuttering. We can hear and see people doing these things, however we can’t see the shame, guilt, anxiety, depression, and social isolation that people may experience as a consequent of having a communication disorder. The impact of one’s experiences from being mocked or made fun of when trying to order a meal can’t be objectively measured by an observer. These aspects typically can’t be observed and are often assessed via self-report, being below the surface or covert features of communication disorders. Our experiences with stuttering, the psycho-emotional-social ones, are what makes having a communication disorder so difficult. With the exception of very few prominent secondary stuttering behaviors such as head jerking that may result in headaches or muscle fatigue, overt stuttering isn’t overly physically demanding, although it may look that way to outsiders. For us, stuttering is our natural way of speaking and doesn’t require much cognitive or physical effort. Some of the more difficult aspects for us are the decreased sense of self-worth, self-confidence, and self-efficacy along with increased self-judgment, shame, guilt, resentment, anxiety, social isolation, and depression that we experience secondary to our stuttering. It’s thinking that we are failures because of not being able to communicate efficiently or effectively. Some people who stutter even report that they spend the majority of their days consumed by the fear of stuttering and spend much of their day planning and dreading communication interactions. Due to the fear and anxiety associated with the moment of stuttering it is often described analogous to the experience of drowning. Again, it’s the perceptions of ourselves and concern of how others may be judging or treating us that can often lead to a traumatic experience. If we haven’t had holistic therapy that focuses on anxiety reduction strategies, cognitive reframing, etc we may be experiencing most speaking situations as repeated traumatic events. To the contrary, we also may not benefit from people trying to “save us” from these situations by talking for us or over us or finishing our sentences either. Those experiences may further instill some of our already prominent negative thoughts and feelings. So in short, the top 10% of the iceberg as Joseph Sheehan depicted back in the 1970’s is comprised of the overt, observable, stuttering, while the 90% submerged below the surface of the water are the negative thoughts, feelings, and social impacts that we experience living with a communication disorder. How has our view of how stuttering should be treated evolved over the years? Stuttering has likely been around for thousands of years with notions of casual and treatment factors mimicking the society and technology of the times. Descriptions and depictions of stuttering appear in the Bible from Moses and others and in cuneiform pictographs that have been found on clay tablets from the Mesopotamian civilization. Being that stuttering has such a pronounced impact on an individual’s life and likewise stands out impacting members of the societies who are exposed to people who stutter, there have been speculations for millennia regarding the etiologies and treatments of stuttering by a variety of people. Some of those people who stutter and others who have expressed their beliefs regarding stuttering are very historically prominent figures (e.g., Aristotle, Socrates, Plato, Isaac Newton, Charles Darwin, Lewis Carroll, Sigmund Freud, Winston Churchill, and Joseph Biden among many others). As a brief historical recap (for more historical context please refer to Hudock & Alteri, 2013, [http://isad.isastutter.org/isad-2013/papers-presented-by-2013/ ]), stuttering was treated in Grecian and Biblical times by prayer, recommended isolation, ingestion of wine or the inverse very noxious substances (goat feces), sensory-motor activities (talking with pebbles in one’s mouth or talking in loud crowds or by the sea), and over practiced and articulated productions. In the Middle Ages it was treated by blood-letting, mutilations to the tongue, trephination (drilling holes in the skull), prayer, and over practice. In the 1800’s it moved to two primary approaches of anatomical dissection of the tongue (Johann Dieffenbach would surgically remove triangular pieces of the posterior section of the tongue, resulting in nearly a 50% mortality rate to several hundred children who underwent the procedure) and behavioral approaches such as acting lessons that incorporated over articulating and over pronouncing. In the late 1800’s and early 1900’s it was still treated behaviorally through psychological interventions and over-practicing, but was also treated using a variety of mechanical pieces of equipment resembling torture style devices. In the mid 1910’s the profession of Speech Language Pathology, more akin to how it’s currently recognized, was originated, which further shaped the treatment of stuttering into more behaviorally oriented paradigms. During this time treatments ranged from institutions staffed by former stuttering program graduates to psychological approaches focused on behaviorally altering speech patterns and improving “mental hygiene”. Most of the specific techniques from this time aren’t well known, but some that are include the use of pseudostuttering (fake stuttering) to improve confidence and decrease the severity of the overt stuttering. Wendell Johnson and Charles Van Riper were two of the early pioneers in the treatment of stuttering (both being PWS themselves). These behaviorally focused approaches continued in this style for several decades, trying to reduce the stuttering back to where it was during its developmental infancy. Via Wendell Johnson’s Semantogenic and Diagnosogenic views on stuttering, he believed that stuttering was caused by attention being drawn to the stutter and labeling someone as a person who stutters (this ended up being disproved via Mary Tudor’s thesis and a number of other such studies), therefore treatment for kids who stutter was indirect, not explicitly mentioning stuttering, but rather modeling slowed fluent speech. Similar indirect treatment methods are still occasionally used today. Charles Van Riper created the Stuttering Modification approach that paralleled some of Johnson’s practices for adolescents and adults who stutter, but Van Riper’s Stuttering Modification is still one of the prominent approaches used today. The 1950’s through the 1990’s saw much influence from the field of Psychology with operant conditioning, Behaviorism, and other Learning Theories. From the 1950’s through the 1970’s there was a surge in the methods and practice of operant conditioning (e.g., time-out procedures when someone stutters, electrical shock reinforcement methods, token economies of rewards and punishments etc, and auditory feedback procedures). In the 1980’s through the 1990’s there is a boom of Fluency Shaping, as described above. In the mid 1990’s through present day much research came out revealing outcomes from the different Fluency Shaping and Stuttering Modification approaches (again, as described above), which resulted in a decline of Fluency Shaping programs (not necessarily practices by non-specialized clinicians). It should be noted that Stuttering Modification was a present parallel from its inception to present day. With the documented evidence regarding the dramatically different outcomes from approaches taken for the treatment of stuttering and more of a research and clinical emphasis on the experience of stuttering, a shift towards holistic approaches began occurring in the mid-2000’s. There are some major challenges in continuing to progress towards holistic approaches. As examples, not many Speech Language Pathology Graduate training programs have an academic faculty member with a specific area of expertise in fluency disorders, not all programs (graduate or undergraduate) have specific courses on fluency disorders (one program that I’m familiar with only has a two-week section embedded in a motor speech course), and students are continuing to graduate without the number of assessment or treatment hours in fluency disorders. Fluency disorders are a specialized area where students and clinicians benefit from additional training in psychological, emotional, and social paradigms and practice (counseling coursework and practical experiences), which seldom happens in our field. Therefore our next generation of clinicians aren’t consistently receiving adequate training or experience to treat PWS. Due to some of these constraints, practicing clinicians may be using outdated practices focusing treatment on those observable features that are more easily recognized. For example, I’ve seen several clinicians in rural areas still using airflow-style therapies that haven’t been present or support by the research literature since the early 1980’s. My hope as a person who stutters, Speech Language Pathologist, Researcher, and Academic is that we as a profession will alter our SLP student training programs to become more holistically focused to align with the more current paradigm in our field, as is supported by the current state of the research. Are there any obstacles to getting professionals to implement holistic stuttering therapy? Yes, unfortunately there are some consistent obstacles that come up when trying to progress to holistic approaches. Some of those were talked about above, the training and lack of experience. Again, not many training programs have academic faculty members who have specific areas of expertise within fluency disorders and students often don’t receive the necessary training, hours of assessment or treatment, or experience working with PWS. They often don’t take classes on counseling theory or practice exposing them to psychological, emotional, and social domains for treatment. Having such classes and experiences would also likely expose them to Rogerian approaches rather than the Medical hierarchy model of treatment we typically practice, further broadening their view of therapy and the client. Other consistent obstacles revolve around timing, reimbursement, and personnel factors. For example, without having had adequate training or experience to take a holistic approach to stuttering therapy a school-based Speech Language Pathologist may have 60-120 (or more) clients on their caseload (some of which are mandated to be seen twice a week), which means back to back sessions of groups of clients throughout the day while still having to complete paperwork around school hours and in the evenings. Therefore they don’t have time to further their specialized training. Reimbursement is similar, in that when doing presentations I often receive the question how do you get this type of approach reimbursed? How can your write meaningful and measurable goals? Some of this comes from the entrenched practices in our field of constraining our Specific / Significant, Measurable / Meaningful, Achievable / Action-Oriented, Realistic / Relevant, Timely / Trackable (SMART) goals that are often thought of as who will do what for how long under what conditions. These practices often miss the lived experience component, which may be more difficult to initially develop goals for aimed at a holistic client focus. The more practice clinicians get at writing holistically-focused goals and documenting gains, the easier this obstacle is to overcome. The personnel topic includes a number of factors from the SLP, access to populations and support, access to and willingness from collaborators, and support from administration. Does the clinician have children or people who stutter on their caseload and if so do they create enough of a justified need for time devotion for further specialized training? What supports are available to the clinician (local academic who is willing to consult and do classroom presentations, continue education offerings etc, local National Stuttering Association chapters or FRIENDS of People Who Stutter and Stuttering Foundation workshops). I know many other academics, like me, who stutter and got into our field of Speech Language Pathology to help others who stutter. So many of us love when SLPs reach out to us with these types of requests. I typically do 15-20 pro bono consultations, telehealth meetings, in-services, and classroom presentations with kids who stutter per year, which isn’t overly uncommon. If we as SLPs don’t have the training, expertise, or time to develop those aspects to focus on the psychological, emotional, and social well-being of our clients, we should reach out to those professional that do. For example, psychologists, counselors, and school counselors are specifically trained on theories and applications for treating psychological, emotional, and social domains. There are a number of different collaborative models that may work better in one situation than another (e.g., multidisciplinary, transdisciplinary, interdisciplinary, or interprofessional), but utilizing other trained personnel is a great way to support our holistic client’s needs and growth. There are many rewards and inherent challenges that come from working with other professionals. Working with other professionals enhances our own professional identity and confidence and typically results in higher client and clinician reported satisfaction and outcomes. Some of the challenges are not unlike those expressed for holistic approaches; time, reimbursement, protection of professional territory etc. Prior to exploring this collaborative holistic approach with another professional, the SLP should educate the person on the experience of stuttering, the psychological, emotional, and social factors often experiences by PWS and recommend specific areas of growth and advancement based on the literature. Some of the more pronounced experiences that lead me to explicitly stating that are what I’ve heard from clients, students, clinicians that SLPs have had them drink water when they stutter, that the SLP laughed and made fun of an adolescent child when they told the SLP that they were mocked and bullied (mimicking the child similar to the scene from the movie the Water Boy), clinics using bite-blocks for stuttering therapy, very outdated airflow strategies already commented on, and counseling professionals having past clients tap on their head in certain areas when they stutter and a School Counselor stating, “Why would I work with them, they stutter?” (regarding a student who yes stutters, but also has a history of self-harm and verbalizing suicidal intents). The personnel also refers to the need to include other members in the therapy experience, such as teachers, parents, friends, other peers, and siblings etc. Lastly, depending on administrators training, beliefs, and other factors, barriers might be present for implementing a holistic approach. Most of these larger barriers to taking a holistic approach to therapy can be overcome when professionals work together advocating for their clients. Small changes can have big impacts, so when the larger barriers are too great to overcome, one can still institute holistic ideals and practices at the individual and personal levels, it’s worth it. What aspect of your research are you most proud of? The aspect of my research I’m most proud of is seeing the positive impact on clients, student clinicians, and professionals from our holistic interprofessional stuttering clinic actualized in life orientation shifts. During the clinic through years after you see how being a part of such a special experience changes people forever. Clients consistently report significantly decreased impact from stuttering in psychological, emotional, and social domains, have shorter durations of stutter with less concomitant distracting behaviors, are socializing more, have increased quality of life and social interactions, and continued positive changes in confidence. Many clients have reported living life on their terms rather than feeling like they had to just survive from situation to situation. Students that we’ve followed up with report continuing to value interprofessional collaborations, other professionals, and having the client be the primary focus of their therapy. When the student sees and values the client before the disorder and symptoms that they present that’s what makes me proud. Allowing student clinicians to be a part of our stuttering world through pseudostuttering and the relationships built with clients when taking a holistic approach changes people for the better. I’m proud to have contributed to the knowledge-base and call for emphasizing holistic, person-centered, approaches in our field. The clients and their experiences should be paramount in our minds when doing therapy, rather than the practices we use to remediate or compensate for disorders. Let’s help people start living their lives on their terms. What is your advice for SLP graduate students? Being an SLP Graduate Student is tough, please remember to: Have self-compassion: Remember that becoming a highly qualified caring professional is a journey, not something that we do to check off a box. Be proud of where you are and appreciate the progress you have made to get here. Take time along this journey called life to reflect on the moments and experiences that have led you here. Do self-care activities: Caregiver and Compassion Fatigue is real and may come on before you are aware of it. We are equal team members of our therapeutic alliances and if we expect our clients to do things to take care of themselves, we should have similar expectations for ourselves. The literature in our field consistently reveals high levels of professional burnout, low quality of job satisfaction, and poorer client outcomes for clinicians who don’t practice self-care. Enjoy the moments with your clients: Be present and connected with your clients and their experiences. Take moments to step back from the task at hand and connect with your clients, they’re why we got into the field in the first place. You will find the more you allow yourself to be mindfully present in therapy and with your clients the more you will enjoy our profession. Value the client and their experiences: Seeing the client before the disorder then planning treatment appropriately allows you to have a broader view of their functioning and the multitude of factors at play. Attend to their psychological, emotional, and social well-beings by taking a holistic approach.