This article was published in the Spring 2001 edition of the British Stammering Association's magazine 'Speaking Out' courtesy of SIGNAL, the magazine of the Special Interest Group Dysfluency of the Royal College of Speech and Language Therapists.
By Guet C Lee, Speech and Language Therapist
Guet Lee has been working as a speech and language therapist with adult dysfluent clients as part of her caseload since 1996. She first worked with this client group in Hull where she also participated in some of the meetings of the Hull and East Yorkshire Stammerers' Self Help Group. It was here that she first met Rob. Over subsequent meetings she was impressed by changes in Rob, in terms of speech and self confidence, which he attributed to attending the 'The Starfish Project'. The differences Guet observed pre- and post- Starfish intrigued her and motivated her to contact Anne Blight with a view to attending the programme.
In her current post at Tees and North East Yorkshire NHS Trust, with responsibility for adult dysfluency, she integrates aspects of what she learned from visiting the Starfish programme in her work with adults who stammer.
When I first came across the Starfish Project I was intrigued, more than anything, by its name. Initial impressions of undersea explorations and the detailed study of marine life soon gave way to a great deal of interest. The Starfish Project entails two and a half days of intensive stammering therapy for adult stammerers. It is run by Anne Blight with the aid of her husband, David. Anne used to have connections with Dave McGuire but left to establish her own course. She uses the tale of starfishes washed up on the shore and a boy who threw them back into the sea one by one, to the chagrin of an observer who wondered what difference this would make because there were so many of them. The boy's response was, "made a difference to that one" as he returned each individual starfish to the sea. Hence, the name of the project underlines its most important principle, i.e. that it can make a difference to the life of each individual stammerer.
Through my years of working with adult stammerers and knowledge of recent research, I have believed strongly that technique work alone is not sufficient to maintain fluency gains. To me, what held more strongly was attitude change and psychological reconstruction. I viewed technique work as an adjunct to, rather than a replacement for, these. Maintenance of fluency was more likely where both approaches were combined. Another strongly held belief was that there must be, wherever possible, long term support for the client who leaves therapy. A question, or doubt, was - can intensive therapy really work without regular follow-up? It seemed unlikely that an adult stammerer who had construed himself as a stammerer for most of his life would be open to cope with and maintain sudden fluency gains without regular support. The experience of joining the Starfish Project, as an observer and participant, in January caused me to reflect on these beliefs and at best modify some of them.
To summarise, Anne Blight's two and a half day course covers costal breathing, desensitisation, avoidance reduction, phone work, positive thinking and many transfer activities. Video recordings of group members are made each day. Testimonies from ex-course members which emphasise the importance of seeking support through a phone list, and the hard work and motivation involved in this approach, are shown. These testimonies provide evidence that costal breathing, together with support and motivation does work. Gains have lasted 18 months - two years after therapy. I thought testimonies from ex-course members were an excellent way of getting the message across.
Talking to ex-course members about their experiences of speech and language therapy, a frequent comment was that following therapy they still stammered even if the nature of their stammer had changed. Many a time I got the impression that, from their perspective, using techniques brought fluency gains, which in turn led to attitude change (in that order).This ran contrary to my previously held belief that it is attitude change that helps techniques succeed. I had to modify my beliefs to include this other possibility. However, whatever works for the majority, there will always be exceptions. Technique work may not be suitable for everyone. Not everybody needs a technique. Different clients might need different techniques. This is an important factor to bear in mind, considering costal breathing is the only technique taught in this programme.
I also feel that although it was good to discuss therapy with ex-course members, one must be aware that these were the ones who had used the technique successfully - what about those who had not? We did not hear from them.
I thought one of the most positive aspects of the course was the clear and concise way in which costal breathing was taught. Yet another attractive feature was the phone support that Anne has built up over the years. This is a phone list of certain ex-course members, Anne and David included, who are willing to be rung up at any time to share problems and other matters. This support is potentially life long. I can see that this form of support would be useful for course members who attend from the length and breadth of the country. However, I do wonder about evaluating the usefulness of this form of support. For me, an essential question, which remains to this day, is to what degree does this phone support work?
On the question - can intensive therapy really work without regular follow-up? It would seem that the starfish answer is - obviously not; as evidenced by how maintenance has been achieved by ex-course members. This further reinforces my belief that, while intensive courses may be wonderful, without regular support relapses are likely. I would like to see maintenance held for far longer than the two years exhibited by certain ex-course members. Perhaps given time, the Starfish programme will prove itself in this respect.
Another strength of the course was the range of topics covered, e.g. avoidance reduction and positive thinking. However, these topics were covered mostly through the presentation of ideas and not through practical activities and discussion. My other criticism would be that one main aspect of these topics was frequently focused on. For example, avoidance was covered through urging course members not to avoid, but rather, to be open about their stammer. Sometimes I felt that the purpose of these non-technique topics was emphasised more than the methods to achieve them. It might also have been useful to spend time brain-storming varied ways of positive thinking, reducing avoidance and desensitisation. Perhaps time constraints did not allow this.
Emphasis on technique and the transfer of techniques may work really well for a certain type of stammerer, i.e. those with an overt stammer. I wondered how easy it would be for those with predominantly covert stammering to risk an open stammer in order to practise the technique in the space of two and a half days when they have been successfully avoiding for most of their lives. Anne admitted this was a worry.
I also liked the way transfer activities were of relevance to people's lives. For example, costal breathing was used during evening meals, at lunches and when paying hotel bills - all things which mattered during the two and a half days which were spent at a hotel. Most of the time there wasn't any artificiality about it. Even the last half day (spent making contacts with the public in a shopping centre) involved mostly necessary purchases and relevant enquiries.
In conclusion, I feel The Starfish Project is an important course and attending was a useful experience . Perhaps the right approach would be to view the programme as initiating change which will continue even after the course has ended - with the right amount and type of support. The commitment and genuineness of the two organisers was obvious.I hope The Starfish Project will continue and develop its strengths.