Adult speech and language therapy

Referral

• You may be referred to a Speech and Language Therapists whilst in hospital
• Your GP or other professional may refer you as an outpatient
• You may refer yourself into the service

You can contact us by email: cdda-trstaffcentraladmin@nhs.net or call: 01388 455 200

Triage

We want to make sure you receive the service which is right for you. This process is called triage. If you have been referred from community we may give you a call to ask about your communication skills and needs, your goals for therapy and to tell you about your service options.

Appointment

Inpatient referrals are usually seen within 1-2 working days. Community referrals will receive an appointment letter through the post once an appointment slot is available. There may be a waiting list for community referrals. To find out your position on the waiting list, please call: 01388 455 200 and we will try and find a day and time that best suits you.

Assessment

At your first appointment we will give you accessible information about our service and ask you to consent to treatment. During your first appointment we will:

• find out about you, your communication and how your communication difficulties are affecting your life
• assess your speech and language to help us understand your specific communication skills
• give you advice on effective communication strategies and support for managing your communication needs.

Therapy

We will talk to you about your goals for therapy and agree with you the best route to reach them.

Therapy options include one to one therapy, group therapy, computer therapy, conversational partner therapy and other support and advice. 

Review

Review appointments are a chance to catch up and see how you are managing, tell us about any concerns you may have or adjust your treatment plan to your needs. Review appointments may be at home, in clinic or via telephone.

Discharge

Sometimes communication difficulties do not get better. Our goal is to help you maximise your specific communication skills and ensure you have all the techniques and support you need, to feel confident about your communication. We will plan your discharge with you and ensure you have access to on-going support as required.

Re-referral

You can ask your GP or any other professional to refer you back to the Speech and Language Therapy service at any time, or you can refer yourself. Please email: cdda-trstaffcentraladmin@nhs.net or call: 01388 455 200

Aphasia is caused by damage to the language centre in the brain. For right handed people, language is usually stored in the left hemisphere. However, left handed people may experience language difficulties after a right hemisphere stroke. Aphasia can affect understanding, talking, reading and writing - this is because the same part of the brain is used for verbal and written communication. Aphasia on its own does not affect intelligence. By law (Mental Capacity Act 2005) all information must be presented in an accessible format and all means possible taken to support successful expression.

Aphasia affects you, your conversational partners and how you participate in your local community and everyday life. Finding your way forward with Aphasia can feel overwhelming. Your Speech and Language Therapist will explore how Aphasia impacts your life and how to tackle the challenges it brings. Strategies to help communication with aphasia, include:

• Take lots of time
• Reduce background noise
• Use short sentences                                                                                
• Stress key words
• Use gesture
• Try writing or drawing

Communicating with Aphasia can be really frustrating. Sometimes the best thing to do is stop and try again later. Feeling of frustration, anger or upset only makes communicating harder.

Speech Dyspraxia (also known as apraxia of speech) is caused by damage to the part of the brain that co-ordinates movement. Messages sent from the brain that tell our muscles how to move, get jumbled up. Dyspraxia appears as groping, un-coordinated movements. Sometimes the target sound may be achieved and sometimes it is not. Speech can sound like nonsense. Dyspraxia is a motor programming disorder. Cognition, building words and thoughts, sentences, muscle strength, range and speed are intact. Messages sent from the brain to tell the speech muscles how to move to say the words get jumbled up. Dyspraxia does not affect intelligence.

To help manage speech dyspraxia:

• Take plenty of time
• Try and stay relaxed
• Use gesture, facial expression, body language to support verbal communication
• Try writing or drawing
• Aim for relaxed social communication, words will come easier in these contexts
• Avoid feelings of frustration, upset or anger. These are normal reactions but they have a negative impact on successful speech. Try and relax and keep calm. If necessary, stop and come back to the conversation later.

The Speech and Language service will work with you to:

• Assess your speech skills
• Provide you with
• Strategies to manage the dyspraxia
• Activities to reduce impairment
• Support and advice

Dysarthria is caused by weakness or in co-ordination of the speech muscles and it affects intelligibility. For clear speech, the lips, tongue, soft palate and vocal cords have to make very precise movements. Speech is powered by our breath. Changes in breath support for speech can also affect intelligibility. Common causes of dysarthria include; Stroke, Parkinson's and Motor Neurone Disease. Different types of dysarthria have different symptoms. Speech may sound too fast or slow, too quiet, monotone or expressionless, slurred, nasal or jerky.

Dysarthria does not affect intelligence. Dysarthria can make it difficult for listeners to understand. Dysarthria can make you feel embarrassed, fed up, frustrated, angry or upset. Managing dysarthria can be tiring and effortful. These strategies may help reduce the impact of dysarthria and support the listener to understand your message:

• Reduce background noise …. Turn off the TV, move to a quiet room
• Go slow! Give your muscles time to make the speech movements
• Make sure you have good breath support
• Use short sentences
• Stress key words
• Over articulate / exaggerate speech muscle movements
• Try writing
• Support what you are saying with body language / gesture
• Ask your listener to feedback if they don't understand
• Use a communication aid

The Speech and Language service will work with you to:

• Assess your speech skills
• Provide you with
• Strategies to manage the dysarthria
• Activities to reduce impairment
• Support and advice

The Speech and Language Therapy department can support patients with Motor Neurone Disease  who would like to 'bank' their voice. A 'banked' voice can potentially be used at a later date when a patient experiences communication difficulties as part of their condition. Once a person's voice has been 'banked' it can be used on certain voice output communication aids which speak messages that have been typed on to them. These types of devices often have generic voices with no significant choice as to the type of accent the voice might have. If a patient has banked their voice then it will be their voice that will be used to speak the messages they type. Given our voice is a large part of our identity it is crucial that we are able to offer a voice banking service to our patients with a progressive neurological condition.

There are various websites available that offer a voice banking service which guide the person through a range of audio recordings of their voice which are then stored on the website. Once recording is completed, a synthesised voice is developed which will endeavour to match the person's tone, pitch and intonation.  The voice recording process requires access to the internet, a good computer (that responds quickly) and a high quality headset/microphone to make the recordings.  The Speech and Language Therapy department, with the help of the Motor Neurone Disease Association, has two laptops and two recording headsets that we can loan to patients for short period of time to allow them to record their voice more easily.

For more information about voice banking, contact the Speech and Language Therapy department by telephone: 01388 455200. For more information on voice bank training, please email: Richard.cave@mndassociation.org

Cognition is the word given to how our mind plans and organises. We use speech and language as tools to express our thoughts, therefore changes to cognition can affect communication. Cognitive processes include attention, memory, organisation, problem solving or reasoning, executive functions, perception, judgement, orientation or reasoning. Cognitive impairment affects communication because cognition is the first step in the process of communication. For example, we use skills such as:

• attention to focus on and filter information
• memory to retain, store and recall information
• judgement to determine what is appropriate to say, how much information to give

Causes

Cognitive impairments result from damage to the areas of the brain involved in cognition. Causes include: dementia, stroke, head injury, brain tumour, Alzheimer's.

Cognitive impairments nearly always affect communication. They sometime co-occur with language or speech difficulties.

Strategies

There are lots of ways to help reduce the impact of cognitive impairments on language. The strategies that will help you will depend on the nature of the cognitive impairment. Your Speech and Language Therapist will give you advice personalised to you. Some tips:

• Reduce distractions - such as noise - turn off the TV
• Use focus getting devices; such as touch or saying name
• Position yourself for good eye contact
• Use short sentences
• Write down key words
• For memory difficulties consider keeping a diary, or use reminder features on smart phones
• If sequencing / organising is challenging, make plans / check lists
• Double check understanding

Technology can be used in lots of different ways to support communication. The types and ways in which technology can be used to support communication will depend on visual, motor and cognitive skills as well as motivation and for some uses, language skills. Your Speech and Language Therapist can give you advice regarding the appropriate use of technology for your needs. Technology can be used in different ways. Communication access by presenting information and supporting expression in multiple different formats. For example, a doctor showing you a video of a procedure helps support the verbal description of it. Examples of tools that support communication access include:

• NHS Easy Info Zone
• Aphasia friendly iBooks
• You Tube
• Google images
• Communication Therapy can be provided via online software programmes and apps. Enabling you to work independently at your own pace and improving your frequency of access to therapy.

It's important to choose the right type of therapy to target your specific communication difficulties. Discuss your options with your Speech and Language Therapist. They will be able to advice you on the evidence base and effectiveness behind all the many choices out there.

• Local support directories 
• NHS aphasia information 
• The National Aphasia Association - important information 
• Aphasia software finder
• NHS dysarthria information
• British Aphasiology Society
• Changing Faces
• Cleft Lip & Palate Association
• Different Strokes
• Headway - the brain injury association
• Huntington's Disease Association
• Macmillan Cancer Support
• MS Society
• Parkinson's UK
• Progressive Supranulcear Palsy Association
• Royal College of Speech & Language Therapists
• Samaritans
• Stroke Association
• Alzheimer's Society
• British Dyslexia Association
• The Complementary Cancer information
• MND Society UK
• Watch a video on What is Aphasia?
• Watch a video on Communication Strategies
• Watch a video on What is Dysarthria?

Stammering is a struggle to get words out. Typical features of stammering include repetition of sounds / words, prolonging initial sounds / words or not being able to produce any sound. Stammering is often accompanied by physical tension in the face and body.

Stammering is a variable and unpredictable condition. People who stammer can often experience periods of fluent speech but may also struggle to speak at other times.

People who stammer may avoid words or situations they feel will increase their likelihood of stammering. In some people who stammer, they may avoid things to such an extent that their stammer will be completely hidden. This is known as "interiorised" or "covert" stammering.

Stammering is often compared to an iceberg: there is a lot going on underneath the surface which others do not see. The visible part of the stammer includes repetition of sounds/words, prolonging initial sounds, and being unable to produce sounds. Under the surface part of the stammer includes avoidance, negative thoughts, and feelings such as frustration, embarrassment and shame. These hidden features have a role in maintaining the stammer. Both visible and hidden features are addressed in therapy.      

What causes stammering?

Stammering is not caused by one single factor. For each person, there are a number of factors which contribute to their vulnerability to stammering and to whether their stammer is likely to continue. In young people and adults, there are 5 main areas which may contribute to stammering. These are:

• Neurophysiology - in some adults who stammer, there are differences in the way their brains are structured or how they work, compared to adults who do not stammer.
• Pharmacological - stammering can occur as a side-effect of medication or recreational drug use.
• Psychogenic - stammering may arise from a psychological response to stress or trauma.
• Re-occurrence of a childhood stammer - a childhood stammer may re-emerge when coping strategies are no longer working for that person.
• Idiopathic - any contributing reasons to the stammer are not known.

In children, young people and adults, there are also some factors which may contribute to the occurrence of stammering. These are:

• Linguistic factors - stammering is more common at the beginning of sentences, and in sentences with long and complex structures.
• Sex - stammering occurs more frequently in males.
• Environmental factors - events or things in the environment can acts as stressors which may coincide with the start of stammering, or stammering becoming more severe.

If you are an adult who stammers and would like to see a Speech and Language Therapist who specialises in working with stammering, you can either self-refer or request referral via your GP.

For self-referral, please contact us by telephone: 01388 455 200 or email: cdda-tr.staffcentraladmin@nhs.net

We understand that using the telephone can be daunting if you are a person who stammers. You may wish to read the following information before you call us so you know what to expect.

1.  When you call, you should select "option 3" for "any other service".

2.  You will be asked for your name, DOB and/or NHS number (don't worry if you don't know this).

3.  You will be asked to confirm your address and telephone number.

4.  You will be asked if you have a religion, what your ethnicity is and what your main spoken language is.

5.  You will also be asked if you want to share your records with other clinical services.

6.  Once the phone conversation is over, a member of the admin team will create a referral and a therapist will look at this then place you on a waiting list for therapy.

You will be invited to an initial appointment via letter.

If you would like to refer by email please begin your email with: 'I would like to refer myself to the Adult Speech and Language Therapy service for therapy for my stammer.' Then, include the following information: 

• Name:
• Date of birth
• NHS No: (if known)
• Address:
• Contact telephone number
• GP name and address:

This section contains information specifically for GPs, who are the main referrers to our service for adults who stammer.

Assessment and therapy for stammering is provided from age 16+ and is available at five hospital sites and delivered by SLTs who specialise in Stammering Therapy.

How to refer a patient

You can refer by writing to the Adult SALT Team at the following address: Central Appointments Bureau, Speech and Language Therapy, Bishop Auckland General Hospital, Cockton Hill Road, Bishop Auckland, County Durham, DL14 6AD

Telephone: 01388 455200

You can also inform your patients that they can self-refer, either by telephone on the above number or by emailing: cdda-tr.centralbooking@nhs.net.

Who to refer

Fluency disorders present in various forms. Some people will have a more obvious overt stammer with evidence of struggle behaviour and speech blocking. Struggle behaviour refers to the person who stammers reacting physically or emotionally to their moment of stammering; speech blocking is where the mouth is positioned to say a word, but no sound comes out, and there is visible tension. Other people who stammer may be appear to be completely fluent with little or no evidence of struggle behaviour or dysfluency in their speech. This is a covert/interiorised stammer and is the result of high levels of word avoidance and frequently high anxiety. Sometimes these people can experience difficulty getting referred for therapy as their difficulty is not obvious. Some people may have a mix of overt and covert symptoms.

People may also begin to stammer later in life due to neurological problems - neurogenic stammer, or sometimes in association with anxiety - psychogenic stammer.

In all cases the stammer itself is just the tip of the iceberg. Many people who stammer report significant distress and frustration with the negative impact the stammer has on their ability to lead a full life.

How to respond to a patient who asks for a referral

1. When you have discussed the stammering problem with your patient and agreed to make the referral to SALT, we would be grateful if you could direct them to the information on this page. This will inform the patient about our services in advance of them receiving an appointment. It will help reduce anxiety by providing information of what they can expect when they come for assessment and therapy. The webpage is designed to be an evidence based educational resource enabling patients to access accurate and realistic benefits of stammering therapy.

How to respond to a patient who is stammering but not acknowledging it

1. Bring up the subject of stammering with them.
2. Ask if they are aware of the Adult SALT service for stammering.
   • If they are not, provide them with the address / relevant search terms (typing "CDDFT Adult SALT stammering" into a search engine will ensure they find this page).
3. Ask if they wish to seek a referral.
   • If they do, inform them referral is straightforward, and that you can refer them or they can refer themselves using the information provided on the website.
   • If they do not wish to be referred, reiterate this website as an educational resource, which also contains links to other websites and support groups.

We appreciate that this conversation may not be easy, but the majority of our clients have told us they were pleased that their GP broached the topic with them.

Variation: Non-Speech and Speech Experiments  

The aim of variation is to enable the person who stammers to explore and experiment with choice and the possibility of change.  Many people may feel that they have no choice in how they communicate or how they stammer but this is not the case.  We begin experiments with change with tasks that are unthreatening but that help the person who stammers to see that they do have choices in how they may think, feel and behave.  This process is referred to as 'loosening'.

Examples of variation of non-speech might include smiling more, maintaining eye contact when people talk to you or pausing before you answer a question.

Speech variation might include: Speaking slower or faster than usual in one conversation and noticing how that feels or speaking with a softer voice.

An example of varying stammering behaviour might involve shortening a prolongation, reducing 'fillers' such as 'ums' and 'ers' or talking to a new person at a bus stop.

Variation experiments are a useful introduction to desensitisation.

References

Kelly GA (1991) The Psychology of Personal Constructs,  2^nd Edn, Routledge, London

Van Riper (1973) The Treatment of Stuttering, Prentice hall, Englewood Cliffs, NJ

Identification

Therapy often begins with a process of understanding the various components of stammering.  We introduce the concepts of overt (observable) and convert (hidden) stammering using the iceberg metaphor.

From there it is possible to specifically identify overt features in more detail, e.g. When do you block? Where do you notice during prolongations? What are you doing with your hands when you block?

It is helpful to be able to explore and understand these core and secondary behaviours in depth but can be challenging.  It may be the first time person has really examined their stammer and this provides a good foundation for the desensitisation work that follows later.

This image of the stammering 'onion' revealing the layers of core and secondary stammering behaviours is useful.  Click here

Following on from identification of overt systems, time is devoted to exploring the underlying features that serve to maintain stammering.  These can have far reaching consequences and cover a wide range of symptoms including: avoidances, emotional responses to stammering: beliefs about self, such as low confidence and low self-esteem and ways of thinking.

Therapists will introduce various tools and approaches to enable detailed understanding of these complex features.

References

Sheenan JG (1958) Conflict Theory and Avoidance Reduction Therapy, Eisenson J Bloodstein O Stuttering: A Symposium, Harper & Row, NY (iceberg)

Van Riper (1973) The Treatment of Stuttering, Prentice hall, Englewood Cliffs, NJ

Desensitisation techniques

Desensitisation allows you to develop a different relationship with your stammer.  If you have been stammering most of your life you may have developed strategies to avoid stammering in order to not experience difficult feelings of embarrassment and shame.

To desensitise you need to begin to allow yourself to stammer while developing ways to feel calmer and less reactive.  This is a process of toughening up and it can be a challenging but important part of therapy.  Through allowing yourself to experience discomfort in a graded way you begin to learn a lot more about you and your stammer and often find that you can manage the stammer differently.

Some examples of desensitisation include voluntary stammering (stammering on purpose), learning to tolerate pauses, making eye contact, speaking in situations that you might normally avoid.  Your therapist will guide and support you through this.  It is a process that often continues long after therapy ends.

Voluntary stammering - this is one tool to help with desensitation

Voluntary stammering is stammering on purpose.  It is useful for people who stammer because:

It encourages people to approach stammering, not run away from it.

It allows a person who stammers to let other people know that they stammer.

It is giving the person who stammers control of when and how they stammer, and how they feel about stammering.

References

Levy, L (1987) Interiorised Stuttering: a group therapy approach Stuttering Therapy, Practical Approaches, Croom Helm, London

Tolerating stammering - this is another desensitisation tool

This is a technique to help you to be more comfortable with stammering openly.

Block modification

Block modification is a technique which is not aimed at helping the person to become fluent but at helping the person to stammer more fluently. It teaches the person to change or modify their excess tension involved in stammering into a way of stammering in a more controlled and easy fashion.

 The following are block modification tools:

Cancellation

When a person stammers they are often rewarded with a few words of fluency if they struggle through the block. Therefore the person with a stammer will learn to push through their blocks in the hope of achieving those brief moments of fluency. Pushing through blocks creates excessive tension which in turn makes the stammer worse.

Post-block modification is a way to come out of that struggle by stopping the push-through with the blocks and replacing those blocks with pausing, after which the stammered word is attempted again but this time with more control. For example:

• The stammered word can be finished in any way that the person can
• After the word is spoken, a pause of about 3 seconds is used
• The person with a stammer will then use the pause to calm down, getting rid of all the tension associated with the stammer
• Whilst in the pause, the stammered word is reproduced silently (this is referred to as the "pantomimed word")
• The pantomimed word is practiced silently in a calm, fluent manner
• After the pantomime, the stammered word is then said but with less struggle

Pre-block

This is anticipating the stammer and modifying the struggle and tension of the stammered word before the word is actually spoken. It is important to pause before the word on which stammering is anticipated. Before the stammered word is spoken all the speech muscles will relax. The person will then think about how to say the word in a relaxed easy manner. Finally the word is spoken in a more controlled manner.

In-block

This is modifying the stammered word during the stammer itself. Once the stammering begins on the affected word, it is important to stop struggling. In that moment of stopping, the stammered word can be modified by either slowing down the block plus releasing all the tension around it, or by slowing down all repetitions. The result would be a modified stammer which is slow and spoken in a relaxed manner.

Rate control

Many people who stammer say they feel under pressure to speak quickly and feel a sense of urgency to get their words out before they stammer. The majority of people who stammer find that slowing their speech rate does increase their fluency. In therapy working with a more relaxed, flexible rate can be helpful, using pauses to allow for breath support and more relaxed articulators.

Pausing

This is to introduce gaps in speech. Gaps in speech are often perceived as spaces in conversation which will allow the person with a stammer to stammer even more. As a result, the person feels compelled to speed up their speech to fill in the gaps in order to reduce the likelihood of even more stammering. Consequently the stammered word becomes more tensed and the blocks are worsened.

Pausing allows time to think, time to be a good listener, time to emphasise words or emotions and allows time for speech control to occur. Pausing is taught in a series of hierarchical steps - initially introducing pausing in two word phrases, moving on to four word phrases, then introducing increasingly more frequent pausing in longer and longer sentences.

Pausing is a valuable speech strategy; people who stammer experience problems because they find it unnatural, as they are used to a fast rate of speech. It will take time to practice pausing and to incorporate it into everyday speech but the rewards are worthwhile as it can result in less struggling with speech. 

Easy onset

Easy onset is a fluency tool which helps coordinate breathing and speech.  It combines breathing out with a gradual onset of voicing, light contact of the articulators and slightly the initial sounds.  It is easier to use following therapy on breathing, relaxation and practice of forming light contacts.

References

Webster RL (1974) A Behavioural Analysis of Stuttering: treatment and theory, Calhoun KS, Adams HE & Mitchell KM, Innovative Treatment Methods in Psychopathology, Wiley, New York.

Pausing

This is to introduce gaps in speech.  Gaps in speech are often perceived as spaces in conversation which will allow the person with a stammer to stammer even more.  As a result, the person feels compelled to speed up their speech to fill in the gaps in order to reduce the likelihood of even more stammering.  Consequently the stammered word becomes more tensed and the blocks are worsened.

Pausing allows time to think time to be a good listener, time to emphasise words or emotions and allows time for speech control to occur.

Pausing is a valuable speech strategy; people who stammer experience problems because they find it unnatural, as they are used to a fast rate of speech.  It will take time to practise pausing and to incorporate it into everyday speech but the rewards are worthwhile as it can result in less struggling with speech.

Rate Controls (you may also hear this referred to Slowed / Smooth speech)

Many people who stammer say they feel under pressure to speak quickly and feel a sense of urgency to get their words out before they stammer.  The majority of people who stammer find that slowing their speech rate does increase their fluency.  In therapy working with a more relaxed flexible rate can be helpful, using pauses to allow for breath support and more relaxed articulators.

Rate control and pausing need to be combined with desensitisation and avoidance reduction and it can be taught alongside easy onset and breath support.

Breathing

Attention to breathing has long been associated with stammering therapy.  Many people who stammer report tightness and tension in the chest and throat and often feel that they hold their breath during tense blocks.

Breathing is a dynamic process so it changes all the time depending on what we are doing or how we are feeling.  For this reason it is not possible to fully control our breathing all of the time.

In therapy, time is spent complaining the mechanics of breathing and learning how to breathe from the diaphragm.  This is useful for increasing capacity and control of the breath and also for relaxation purposes.

From there vocal exercises can be introduced which help with coordination of airflow and voicing in a smooth, relaxed way.

References

Mathieson L (2001) Greene and Mathieson's The Voice and It's Disorders, 6th edition, Wiley, NJ

Avoidance Reduction / Exposure Therapy

One theory is that stammering is the result of two opposing urges: the urge to speak (the approach response) and the desire to hold back from speaking (the avoidance response).  Avoidance reduction therapy aims to reduce the avoidance response.

Some examples of avoidance are:

• Avoiding words - the person who stammers substitutes the word they fear they will stammer on, replacing it with another word which they find easier to say.
• Avoiding situations - the person who stammers avoids situations they think will be difficult e.g. ordering at a restaurant or using the telephone.
• Avoiding expressing feelings - the person who stammers avoids expressing feelings such as upset, because they feel expressing emotion is letting their guard down or letting their stammer out.
• Avoiding relationships - the person who stammers avoids creating and maintaining relationships, through avoidance of activities such as going to the pub or a sports game, avoiding asking or answering questions, and not keeping in contact.
• Avoid self-role - the person who stammers avoids accepting themselves as a person who stammers.

Avoidance reduction therapy is used when the person who stammers has significant levels of avoidance. They may exhibit some of the behaviours shown above.

People are encouraged to gradually move from their comfort zone to their stretch zone using goals set by them.

Therapy may include activities such as: using avoided words in conversation, developing coping strategies to allow the person to enter into situations they would normally avoid, and role play.

References

Sheehan JG (1975) Conflict theory and avoidance reduction therapy, Eisenson J Stuttering: A Second Symposium, Harper & Row, NY

Acceptance and Commitment Therapy (ACT)

ACT is a behavioural therapy used to work with a whole range of varied conditions such as anxiety, depression and pain.  There is good evidence that it can also be very effective in helping people who stammer (Beilby, Byrnes & Yaruss, 2012).

ACT is named after one of its key messages: acceptance.  It focuses on accepting what is out of your control and committing to living your life fully.

ACT teaches a range of psychological skills which will enable the person who stammers to manage difficult thoughts and feelings they may have about their stammer.  They may have strong beliefs that there are things they cannot do because they stammer.  ACT will help them reappraise this belief.

In therapy, a person who stammers will be introduced to a range of mindfulness skills that will help them to manage challenging emotional states that might arise due to stammering.  ACT will also help them to identify what is really important to them, clarifying their values so that they can take action to move towards their goals.

ACT can be used in conjunction with work on fluency techniques.  We adopt the principle that you try to change what you can but accept what is not possible to control.

This metaphor is a demonstration of how ACT works.

• A man is walking along wearing his coat. The wind starts blowing furiously, which makes the man grip tightly onto his coat as he struggles against the wind.
• Later, the wind dies down and the sun comes out, so the man takes off his coat and carries it for the rest of his walk.

The coat represents the man's stammer, the wind represents the energy spent covering up his stammer, and the sun represents acceptance of his stammer. When the man is covering up his stammer, he is using a lot of energy and is struggling, making him unable to enjoy his walk. When the man accepts his stammer, he no longer has to struggle so he can enjoy his walk.

References

Beilby, J., Byrnes, M., & Yaruss, J. (2012). Acceptance and Commitment Therapy for adults who stutter: Psychosocial adjustment and speech fluency. Journal of Fluency Disorders, 37(4), 289-299. http://dx.doi.org/10.1016/j.jfludis.2012.05.003

Beilby, J., & Byrnes, M. (2012). Acceptance and Commitment Therapy for People Who Stutter. Perspectives on Fluency and Fluency Disorders. 22(1), 34-46.

Harris, R., & Aisbett, B. (2014). The Happiness Trap Pocketbook. London: Little Brown Book Group.

Mindfulness

Mindfulness is a form of self-awareness whereby we pay attention to the present moment without making judgements about what we notice. We spend much of our lives on 'autopilot', not really aware of what we are doing or how we are thinking or feeling. Our minds are busy, often distracted thinking about events from the past or worrying about and planning for future events. This state of mind can be a source of distress and unease. Mindfulness practice enables us to observe our habitual thinking patterns and reactions with less judgement and in time we can learn to allow our experience to be as it is. With mindfulness practice we can develop a particular kind of awareness that is more accepting and more compassionate towards ourselves.

Mindfulness Meditation practice is a key factor in many evidenced-based psychotherapeutic interventions including Acceptance & Commitment Therapy (ACT), Mindfulness Based Cognitive Therapy (MBCT) and Mindfulness Based Stress Reduction (MBSR).

Why practice meditation as part of stammering therapy?

There is good evidence to suggest that mindfulness based approaches can be helpful in promoting increased feelings of calmness and relaxation. We experience these benefits not through 'trying' to relax but paradoxically through learning to allow your experience to be exactly as it is without trying to change anything.

People come to therapy with a desire to change that which is causing them suffering or unhappiness e.g. wanting to be fluent and have control of their stammer.  However, in the pursuit of change and control we can struggle against our experience in unhelpful ways. For example it is natural to want to avoid stammering, to try 'not to do it', but this is more likely to increase tension by placing excessive pressure on a system that is hard wired to stammering.

Mindfulness practice invites us to recognise when we are struggling against our experience and instead practice allowing things to be as they are. This is the beginning of acceptance and often change can flow from this.

As Tom, one of our clients, says in his testimonial 'Stammering itself is peculiar in that the more you fight it, the more effort you put in to trying to control it to your will… the worse it gets.'

​​​​​​Mindful Awareness of Body & Breath

Mindfulness based approaches encourage a kindly curiosity to sensations in the body and awareness of breath. This non-judgemental awareness of the body can help people who stammer to tune in to tension in the body during moments of stammering. With practice it becomes easier to identify habitual negative thought patterns that can manifest in the body as muscle tension. This might affect the breathing and speech muscles. 

For example, having the thought 'I hope I don't stammer' leads to feelings of anticipation and fear, resulting in tense breathing and tense muscles in the body and face which can increase the chances of stammering.

Research has shown that mindfulness based approaches can inhibit the fear response in the brain and enable a calmer, more rational response.

Reference 

Research article: Mindfulness Training in Stuttering Therapy: A tutorial for Speech & Language Pathologists. Michael P Boyle Journal of Fluency Disorders 36 (2011) 122-129

Solution Focused Therapy (SFT)

SFBT is a therapy approach which uses questions to encourage clients to generate their own reflections and thinking and in so doing arrive at their own answers / solutions to the problem. These are questions which are not meant to gain information from the client but to lead the client into generating their own solutions.

SFBT believes in focusing on the moment and the positives that each client brings. Focusing on the past is not helpful. The focus is also not on the therapist providing the answers but in stimulating the client to empower themselves with solutions they are encouraged to discover.

Reference

de Shazer (1985) Keys to Solution in Brief Therapy, Norton, New York

Cognitive Behavioural therapy (CBT)

What is CBT?

Underlying CBT is the principle of negative automatic thoughts. These are the negative beliefs and predictions that people who stammer have established based on previous negative experiences. These experiences may have happened on one occasion in the past but because their negative associations have been so strong, the person who stammers will start to expect the same negative effects if they have to experience the same situation again.

For example, the experience of being rejected for a job because of their stammer may lead the person who stammers to expect to be rejected for every single job because of their speech. A vicious circle of fear/anxiety starts to develop around every job interview, leading to increased tension and fear, causing avoidance of job interviews, which creates frustration. This in turn will lead to more fear and anxiety.

How does CBT work?

Speech and language therapists use CBT in stammering by challenging the person who stammers negative automatic thoughts. They help them to identify and elaborate thought records. These thoughts are challenged by asking the person who stammers to explore the justification / evidence for them. Questions asked of people who stammer can include "are these thoughts real?" and "what is the evidence for them?"

People who stammer are also asked to experiment with different but more positive thoughts e.g. they are asked to reflect on why the person who is talking to them looks away when they stammer. The natural conclusion for people who stammer is that the person is ignoring or mocking them. People who stammer are asked to think about other reasons e.g. perhaps the person is looking away because they feel awkward as they do not know how to react to the stammer. People who stammer are also encouraged to problem solve and to experiment more positive ways of thinking around specific speaking situations.

CBT and other approaches

CBT can be used in conjunction with work on fluency techniques. It can also be used at the same time as discussions around what makes a good communicator and enabling the person who stammers to understand the overt and hidden features of their stammer.

References 

Menzies, R., O'Brian, S., Onslow, M., Packman, A., St Clare, T., & Bock, S. (2008).  An Experimental Clinical Trial of a Cognitive-Behaviour Therapy Package for Chronic Stuttering.  Journal Of Speech Language and Hearing Research, 51(6), 1451.  http://dx.doi.org/10.1044/1092-4399(2008/07-0070)

Thomas, N. Pilecki, B., & McKay, D. (2015).  Contemporary Cognitive Behavior Therapy: A Review of Theory, History, and Evidence.  Psychodynamic Psychiatry: 43(3), 423-461.  http://dx.doi.org/10.1521/pdps.2015.43.3.423

Education and Mind-Body Connection

When we experience a threat, whether real or imagined, the amygdala, a small region in our brain responds by alerting the brain to release the stress hormones cortisol, adrenaline and noradrenaline. This is called the fight or flight response. The brain prepares the body to either fight or run away from the danger.

A typical scenario for a person who stammers may be being in a situation where there is a very real expectation of stammering e.g. waiting their turn to introduce themselves to a new group of people. Whilst waiting their turn, they may experience many of the physical symptoms below: heart pounding, shallow breathing, feeling hot and sweaty, the mind will be racing and they may be feeling emotionally off balance. 

The problem is that mostly we cannot fight or run away in the way our ancestors would have done.  However, people who stammer acknowledge that in order to reduce the distress associated with stammering they will actively avoid situations that cause physical and emotional discomfort, e.g. making an excuse to leave the room before having to introduce themselves.  This has the effect of making them feel safe and relieved in the short term but also leads to high levels of anxiety when the next threatening situation looms.  Over time the brain learns to be anxious in those situations where stammering may be anticipated.   People who stammer may develop a whole range of avoidance strategies in order to understandably feel safe.  These safety seeking behaviours however, may be very life limiting and prevent the person from discovering new ways of managing their fears and ultimately of leading a full life.

We can all experience an amygdala response when our senses become overwhelmed due to a threatening situation. Neurologically the amygdala response has the effect of shutting down the thinking /planning part of the brain, the pre-frontal cortex. This explains why we can't think straight or be rational in those situations. This also explains why it is so difficult to put fluency techniques into practice when you really need them. Despite your best intentions, you may find yourself rushing though a sentence and blocking on key words because you are unable to remain calm.

Mindfulness based approaches have been found to be helpful in reducing anxiety, stress and fear responses in that they help to regulate emotions by calming down the amygdala and strengthening the activity in the pre-frontal cortex.

CDDFT Durham Stammering Support Group

The Stammer Support Group meets once a month in the Durham area. We meet on the 4th Tuesday of every month 6-8pm. The venues vary but we give plenty of notice.

The group is comprised of people who have been referred for therapy for their stammer and who wished to meet others for on going support. The group is small and friendly and always ready to welcome new members. Visit the website or find us on Facebook

British Stammering Association

• Website: https://www.stammering.org/
• Facebook (information): https://www.facebook.com/stammeringbsa/?ref=br_rs
• Facebook (support group) : https://www.facebook.com/groups/stammeringbsa/?ref=br_rs#

City Lit

• Website: https://www.citylit.ac.uk/about-stammering
• Facebook (information): https://www.facebook.com/CityLit/

American Stuttering Foundation

• Please note this is an American website so not all information will be applicable.
• Website: https://www.stutteringhelp.org/
• Facebook: https://www.facebook.com/stutteringhelp/?hc_ref=ARQ6mAYF9OISluKiq9ZuoxkHQEjcFPmR_IeLBne7ILxn1SjUJF87l6nHi0HgH3EbBso&fref=nf

NHS Choices

Website: https://www.nhs.uk/conditions/stammering/Pages/Introduction.aspx

Apps

• Headspace https://www.headspace.com/headspace-meditation-app
• Living Mindfully  https://itunes.apple.com/gb/app/living-mindfully/id1078895986?mt=8

Other useful support and resources

• Royal College of Speech & Language Therapists
• British Stammering Association
• CDDFT Durham Stammering Support Group
• CDDFT Durham Stammering Support Group Facebook Page
• Watch a short film on things not to say to someone who stammers
• Patient information
• Watch a short film on Will's Story
• Watch a short film on what brought Will to Therapy
• Watch a short film on Will's expectation of Therapy
• Watch a short film on Will discussing things he wants others to know about stammering
• Watch a short film on Adam's Story
• Watch a short film on Adam's expectations of Therapy
• Watch a short film on Adam's experience of Therapy
• Watch a short film on Adam discussing how he would like others to respond when he stammers
• Watch a short film on Adult Stammering Therapy - What to Expect
• Watch a short film on SLT Stammering in Adults
• Watch a short film on a Patient Case Study
• Watch a short film on Voluntary Stammering
• Watch a short film on What is Stammering?

Dysphagia in adults is associated with a number of different conditions, including:

• Stroke
• Progressive neurological disorders, including dementia, Parkinson's disease, motor neurone disease, multiple sclerosis, and muscular dystrophy.
• Cancer, including head and neck, lung, and oesophageal
• Respiratory conditions, including chronic obstructive pulmonary disease, emphysema, and asthma
• Learning disability, developmental and acquired disorders
• Disorders of the immune system
• Traumatic brain injury

Acutely ill patients in critical care beds, including those with cervical spinal injuries and those with community-acquired pneumonia, Guillain-Barre and influenza can also have dysphagia.  Acid reflux can also result in swallowing difficulties.

How speech and language therapy can help

Speech and language therapists have a unique role in the assessment, diagnosis and management of swallowing difficulties. They:

• Play a key role in the diagnosis of dysphagia
• Help people regain their swallowing through exercises, techniques and positioning
• Promote patient safety through modifying the texture of food and fluids, reducing the risk of malnutrition, dehydration and choking
• Promote quality of life, taking into account an individual's and their families' preferences and beliefs, and helping them adjust to living with swallowing difficulties
• Work with other healthcare staff, particularly dieticians, to optimise nutrition and hydration
• Educate and train others in identifying, assessing and managing dysphagia, including families and the wider health and care workforce

Dysphagia: what can be done to help?

• Exercises can sometimes help to improve the muscles we use to swallow.
• Strategies / postures can sometimes be used to improve the safety of the swallow.
• Thickening fluids can sometimes make drinking safer.
• Altering the texture of the diet can sometimes make eating safer.

Dysphagia: how can the Speech and Language Therapist help?

• Detailed and accurate assessment.
• Accurate diagnosis of dysphagia which may assist with the differential medical thoughts.
• Ensuring safety (reducing or preventing aspiration) with regards to swallowing function.
• Balancing risk factors with quality of life, taking into account the individual's preferences and beliefs.
• Working with other members of the team, particularly dieticians, to optimise nutrition and hydration.
• Stimulating improved swallowing with oral motor/sensory exercises, swallow techniques and positioning.

The impact of speech and language therapy

Early identification and management of dysphagia by speech and language therapists improves quality of life, and reduces the possibility of further medical complications and death.  Improved nutrition and hydration have an impact on physical and mental wellbeing.

Clinical Examination

Look, feel, listen for signs of dysphagia using a stethoscope at times.

Videofluoroscopy

An x-ray where food and drink is mixed with barium so we can see exactly what happens when we swallow.

Fibreoptic Endoscopic Evaluation of Swallowing (FEES)

A small endoscope is passed through the nose to visualise the larynx (voice box) and airway during the swallow.

• Different Strokes
• Headway - the brain injury association
• Huntington's Disease Association
• Macmillan Cancer Support
• MS Society
• Parkinson's UK
• Progressive Supranuclear Palsy Association
• Royal College of Speech & Language Therapists
• Samaritans
• Alzheimer's Society
• The Complementary Cancer Information
• Watch a short film on Tracheostomy FEES Assessment
• Watch a short film about tube feeding in MND/ALS
• Eating with Dignity
• Dementia Eating and Drinking
• Dementia Mouth Care
• Watch a video on What is a FEES?
• Watch a video on What is a videoflouorsocopy?
• Watch a video on Swallowing rehabilitation exercises and swallowing strategies

This section includes various exercises for different aspects of the voice. Here you can find a vocal warm-up and breathing exercises, specific techniques to encourage relaxation, increase voice projection and help to find a comfortable pitch, as well as others. Please follow directions from your Speech and Language Therapist to the exercises which are best for you. 

• Watch a short film clip on Warm-up exercises - Voice exercise
• Watch a short film clip on Dynamic stretches - Voice exercise
• Watch a short film clip on Breathing exercises - Voice exercise
• Watch a short film clip on Tongue roll - Voice exercise
• Watch a short film clip on Chewing - Voice exercise
• Watch a short film clip on Lip trill - Voice exercise
• Watch a short film clip on Tongue trills - Voice exercise
• Watch a short film clip on Accent method - Voice exercises
• Watch a short film clip on Volume & Projection - Voice exercise
• Watch a short film clip on Vocal Function Exercises - Voice exercise
• Watch a short film clip on Lax Vox - Voice exercise
• Watch a short film clip on Resonant Voice - Voice exercise
• Watch a short film clip on Pitch - Voice exercise
• Watch a short film clip on Breath Before Tone - Voice exercise

There are many reasons why the vocal cords may not come together in the way they need to for normal voice production. In the links on the right, there are exercises to help achieve this closure. Please follow directions from your Speech and Language Therapist to the exercises which are best for you. 

• Watch a short film clip on Glottal onset - Voice exercise
• Watch a short film clip on Smooth onset - Voice exercise
• Watch a short film clip on Plosive consonant closure - Voice exercise
• Watch a short film clip on Pops - Voice exercise
• Watch a short film clip on Glides - Voice exercise
• Watch a short film clip on Vocal Function Exercises - Voice exercise
• Watch a short film clip on Creak - Voice exercise
• Watch a short film clip on Sob - ~Voice exercise
• Watch a short film clip on Hmmm - Voice exercise
• Watch a short film clip on Accent method - Voice exercise

Below are exercises to release the muscle tension that causes constriction in the voice box from the sides. Please follow directions from your Speech and Language Therapist to the exercises which are best for you.

• Watch a short film clip on Smooth onset - Voice exercise
• Watch a short film clip on Hmmm - Voice exercise
• Watch a short film clip on Accent method - Voice exercise
• Watch a short film clip on Silent inspiration - Voice exercise
• Watch a short film clip on Stifled yawn - Voice exercise
• Watch a short film clip on Sob - Voice exercise
• Watch a short film clip on Silent laugh - Voice exercise
• Watch a short film clip on Breath Before Tone - Voice exercise

Below are exercises to release the muscle tension that causes constriction in the voice box from the front to back. Please follow directions from your Speech and Language Therapist to the exercises which are best for you.

• Watch a short film clip on Accent method - Voice exercise
• Watch a short film clip on Yawn-sigh - Voice exercise
• Watch a short film clip on Sob - Voice exercise
• Watch a short film clip on Whine - Voice exercise

There are many reasons why the voice box, or larynx, may be held too high in the throat. Below are exercises to help lower the larynx. Please follow directions from your Speech and Language Therapist to the exercises which are best for you.

• Watch a short film clip on Chewing - Voice exercise
• Watch a short film clip on Accent method - Voice exercise
• watch a short film clip on Yawn-sign - Voice exercise
• Watch a short film clip on Sob - Voice exercise
• Watch a short film clip on Whine - Voice exercise
• Watch a short film clip on Lax Vox - Voice exercise

Sometimes people can have difficulty controlling what is known as the 'cricothyroid visor', causing voice problems. There is an exercise to help gain more control over this. Please follow directions from your Speech and Language Therapist to the exercises which are best for you.

Try relaxing your shoulders down, keeping your head level and your back comfortably straight. You can search online for more advice about the best posture when speaking.

Some people can experience paralysis of the vocal cords where one or both cords do not move properly. This leads to poor function of the vocal cords meaning they do not come together to close properly to achieve normal voice production. Below are exercises to help achieve this closure. Please follow directions from your Speech and Language Therapist to the exercises which are best for you.

• Watch a short film clip on Glottal onset - Voice exercise
• Watch a short film clip on Smooth onset - Voice exercise
• Watch a short film clip on Plosive consonant closure - Voice exercise
• Watch a short film clip on Pops - Voice exercise
• Watch a short film clip on Hmmm - Voice exercise
• Watch a short film clip on Glides - Voice exercise
• Watch a short film clip on Accent method - Voice exercise
• Watch a short film clip on Vocal Function Exercises - Voice exercise
• Watch a short film clip on Creak - Voice exercise
• Watch a short film clip on Sob - Voice exercise