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Group therapy for school-aged children who stutter: A survey of current practices
Journal of Fluency Disorders 36 (2011) 274–279
Contents lists available at ScienceDirect
Journal of Fluency Disorders
Group therapy for school-aged children who stutter: A survey of current practices Hilary Liddle ∗ , Sarah James, Margaret Hardman Leeds Metropolitan University, Civic Quarter, Leeds LS1 3HE, UK
a r t i c l e
i n f o
Article history: Received 28 March 2010 Received in revised form 5 December 2010 Accepted 12 February 2011 Available online 1 March 2011 Keywords: Group therapy Children Stuttering Survey
a b s t r a c t Although group therapy is recommended for school-aged children who stutter (CWS), it is not widely researched. This study aimed to explore this provision, using a postal survey which investigated the current practices of Speech & Language Therapists (SLTs) in the UK. Seventy percent of SLT services provided some group therapy, but the level of provision was variable. There was a lack of consensus on what the main aims of group therapy should be. Important barriers to group therapy provision were identified, including a perceived lack of clients’ interest in group therapy, and insufficient numbers of clients able to travel to group venues. This study enhances the profession’s understanding of the provision of group therapy for CWS by identifying patterns of service delivery and highlighting areas of need. Educational objectives: Readers should be able to: (1) Provide a rationale for the provision of group therapy for school-aged CWS; (2) Summarize the factors affecting group therapy provision for school-aged CWS; (3) Summarize the aims of therapy identified by the respondents to this survey. © 2011 Elsevier Inc. All rights reserved.
1. Introduction Group therapy is widely recommended to Speech & Language Therapists (SLTs) as an effective way of managing stuttering in school-aged children (e.g. Stewart & Turnbull, 2007). In recent years, the evidence base for intervention with young children who stutter (CWS) has increased significantly (e.g. Franken, Van Der Schalk, & Boelens, 2005; Jones et al., 2005; Millard, Edwards, & Cook, 2009). In contrast, studies exploring the effectiveness of therapy, including group approaches, for older children and adults remain more limited. Nevertheless, from a theoretical perspective, there is a persuasive rationale for offering this type of approach. By adolescence, many aspects of an individual’s life may become shaped around a negative self-image and fear of stuttering (Guitar, 2006). Addressing affective, behavioural and cognitive responses to stuttering is therefore a critical aspect of the therapeutic process when working with CWS (e.g. Murphy, Yaruss, & Quesal, 2007a). Evidence from psychotherapeutic literature suggests that group approaches may be particularly effective in addressing negative thoughts and feelings by eliminating the participant’s sense of isolation and invalidating his ‘heightened sense of uniqueness’ (Yalom & Leszcz, 2005, p. 6) CWS may have difficulty ‘fitting-in’ at school and being accepted by peers (Evans, Healey, Kawai, & Rowland, 2008), and one of the greatest challenges facing many school-aged CWS is bullying (e.g. Davis, Howell, & Cooke, 2002). Group therapy offers an opportunity for peer support which has been identified as having an important role in counteracting victimisation (Boulton, Trueman, Chau, Whitehand, & Amatya, 1999) and reducing children’s anxiety about bullying (Cowie, Hutson, Oztug, & Myers, 2008). Furthermore, Hearne, Packman, Onslow, and Quine’s (2008)
∗ Corresponding author. Tel.: +44 0113 812 5823. E-mail addresses: [email protected] (H. Liddle), [email protected] (S. James), [email protected] (M. Hardman). 0094-730X/$ – see front matter © 2011 Elsevier Inc. All rights reserved. doi:10.1016/j.jfludis.2011.02.004
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qualitative study suggests that adolescents who stutter have a strong preference for group rather than individual therapy, and Murphy et al. (2007a) suggest that group therapy can play a useful role in therapy for school-aged children. Whilst there is a strong rationale for believing that group therapy can form a useful element of therapeutic intervention for school-aged children, little is known about the level and nature of this provision or about how group therapy provision operates in practice. In other areas of stuttering research, SLTs’ practices and attitudes have been documented using surveys. These have been useful, for example, in identifying wide variations in practice (Davidson Thompson, Mcallister, Adams, & Horton, 2009) and in highlighting the need for ongoing professional development (Crichton-Smith, Wright, & Stackhouse, 2003). The aim of the present study was to explore the provision of group therapy for school-aged CWS, by investigating current practices of clinicians. 2. Method 2.1. Design The design of this study was a survey by postal questionnaire. 2.2. Procedure One questionnaire was sent to each of the 205 paediatric SLT departments in the UK. An accompanying letter requested that the questionnaire be completed by a dysfluency specialist or, where this was not possible, by another SLT in the department who had responsibility for providing a service to school-aged CWS. 2.3. Questionnaire development A questionnaire was developed and piloted. A mixed format of open and closed questions addressed the following areas of practice: 1. 2. 3. 4.
Respondent and service characteristics; Level and mode of group therapy provision; Factors affecting group therapy provision; The main aims of group therapy.
2.4. Analysis Data was analysed using SPSS (Windows version 15.0). Descriptive and inferential statistics were used to summarise information obtained and to explore factors that affect group therapy provision. 3. Results Percentage figures are reported to the nearest whole number. 3.1. Respondent and service characteristics Of the 205 questionnaires distributed, 143 completed questionnaires were returned, representing a 70% response rate. Sixty-eight percent (n = 95) of respondents reported that they were dysfluency specialists. Thirty-five percent (n = 44) of respondents reported that they served inner city/urban communities with 65% (n = 83) serving rural/mixed (rural and urban) communities. 3.2. Level and mode of group therapy provision Seventy percent (n = 100) of respondents reported that their services provided group therapy for school-aged CWS, with 70% (n = 70) of these reporting that they had provided some group therapy within the past year. The majority of group therapy was delivered on an intensive (43%) or a weekly (31%) basis. Forty nine percent (n = 61) of respondents reported that their services had accessed some out-of-district group therapy provision for school-aged CWS in the previous two years. 3.3. Factors affecting group therapy provision Inner city and urban services were significantly more likely than rural/mixed services to provide group therapy (2 (1, n = 127) = 4.11, p < .05), and specialists were more likely to provide group therapy than non-specialists (2 (1, n = 140) = 15.60, p < .001).
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Table 1 Perceived barriers to group therapy provision. Factor
% (n) of non-providers agreeing with statement
Sufficient numbers of clients are able to travel to group venues CWS have sufficient interest in group therapy Parents have sufficient interest in group therapy There are sufficient numbers of school-aged CWS to form groups SLTs are sufficiently confident in facilitating groups for CWS SLT s have undergone sufficient training to enable the provision of group therapy for CWS SLTs have sufficient experience to enable them to provide group therapy for CWS Staffing levels are sufficient to enable the provision of group therapy for CWS There is sufficient availability of suitable accommodation for the provision of group therapy SLTs are sufficiently competent in facilitating groups for CWS SLTs have sufficient interest in group therapy for CWS There is sufficient management support for the provision of group therapy for CWS
16 (6) 18 (7) 23 (9) 28 (11) 31 (12) 46 (18) 46 (18) 50 (19) 50 (20) 51 (20) 51 (20) 58 (22)
Table 2 The aims of group therapy for school-aged CWS (n = 92). Main aim of group therapy Increased confidence Fluency skills Social/communication skills Improved attitude to stuttering (e.g. desensitisation) Peer support Problem solving Knowledge/education/empowerment Cognitive skills (CBT, cognitive therapy, positive thinking) Identification of stuttering behaviour Modification of stuttering behaviour Developing specific skills (e.g. telephoning)
% (n) identifying aim 75 (69) 70 (64) 58 (53) 40 (37) 39 (36) 21 (19) 20 (18) 15 (14) 12 (11) 12 (11) 10 (9)
Perceived barriers to the provision of group therapy were explored by asking respondents to rate their level of agreement with a series of statements on a 5 point Likert scale. Table 1 shows the percentage of those participants reporting that they did not provide therapy (non-providers) who agreed or strongly agreed with each statement. 3.4. Group therapy process 3.4.1. Therapy aims Providers were asked to identify their main aims of group therapy. Responses were coded and frequency counts performed. Responses are summarised in Table 2. Chi-square analyses indicated that there were no significant differences between specialist and non-specialist providers in identified aims. 4. Discussion 4.1. Patterns of delivery The majority of respondents reported that their service provided some group therapy for CWS, although it should be acknowledged that services that provide group therapy may have been more likely to respond to the survey. A number of factors that have the potential to influence group therapy provision were identified. Results from this survey indicate that services based in inner city and urban areas are more likely to provide group therapy than those in rural or mixed areas. Research in fields, such as general medicine, has shown that distance from health service provision is negatively related to its use (Watt, Franks, & Sheldon, 1993). This may be partly due to variations in people’s inclination to access services, for example it has been shown that perceived need is inversely related to remoteness (Bloor, Horobin, Taylor, & Williams, 1978). Another possible explanation might be that sparser and more widely distributed populations make it difficult to obtain the critical numbers needed to run groups. Table 1 suggests that both of these factors may be important in non-provision of group therapy. Access to services has been improved in other health fields through the use of outreach clinics (Haynes, Gale, Mugford, & Davies, 2001), mobile day care services (Le Mesurier & Duncan, 2000), and telehealth (Schopp, Demiris, & Glueckauf, 2006). Telehealth has also been used to provide individual therapy for people who stutter (PWS) in large, sparsely populated areas, such as in Australia (Carey et al., 2010). Although these potential solutions have limited application in group therapy, telehealth may offer some benefits through the use of web based social networking sites. Another possible solution is the provision of residential courses (Edwards, Stewart, O’Leary, Williams, & Turnbull, 2005)
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A perceived lack of both parent and child interest in group therapy was identified as a possible barrier to group therapy provision (Table 1). This finding has similarities to those described by Joffe and Pring (2008), who reported that parental motivation is a factor in SLTs’ clinical decision making. It is unclear from the current study whether or not clients do lack interest in group therapy, or whether this is simply therapists’ perception. Zebrowski (2007) suggests that the clinician’s expectation of therapeutic success is an important factor in the client’s process of change. Clinician factors, such as lack of confidence (Table 1), which were found to be barriers to intervention may have therefore also impacted negatively on clients’ level of interest in group therapy or on therapists’ perceptions of clients’ level of interest. A further factor in the perceived lack of clients’ interest may have been anxiety about group therapy. Issues such as these are currently being explored, in depth, in further research involving SLTs, and CWS and their parents. 4.2. Group therapy process Therapists who took part in this study used a wide variety of aims, and overall there was a lack of consensus on what the main aims of therapy should be. Different sub groups of respondents did not use different aims of therapy, although other research, for example Davidson Thompson’s (2008) survey, has shown that specialists and generalists have different therapeutic goals for PWS. Respondents to the current survey took an eclectic approach to therapy with many individuals reporting a range of aims. It was surprising, given the issues that CWS have with sociodynamic relationships (e.g. Davis et al., 2002), that addressing teasing and bullying was not widely identified as an aim of therapy. However peer support, which is known to play a role in reducing anxiety about bullying (Cowie et al., 2008), and confidence-building, which plays a role in helping children to respond assertively to bullying (e.g. Murphy, Yaruss, & Quesal, 2007b) were widely used aims. 4.3. Recommendations for clinical practice When planning group interventions, SLTs should give careful consideration to the practicalities of group therapy provision. In particular, the needs of children and parents who might benefit from group therapy, but who may be reluctant to attend, should be addressed. For example, children could be encouraged to experience a single session of group therapy before committing to a full course of therapy. The most frequently used aim of therapy was to increase children’s self-confidence. This indicates that the need to address the underlying affective, behavioural and cognitive aspects of stuttering is widely recognised. There are a number of recommended texts which give the clinician practical suggestions about how to address these issues with children, both individually and in groups. For example, Guitar and Reville (2003), Murphy et al. (2007a), Stewart and Turnbull (2007), and Williams (2006). 5. Conclusion Although many SLTs who responded to this survey reported that their services provided some group therapy for CWS, the level of provision varied. It is important to overcome the barriers to group provision, identified by this study, or to explore alternative ways of achieving the benefits that group therapy offers. A lack of consensus on the aims of group therapy raises questions about how group therapy might facilitate change in the child’s experience of stammering, and to what part of the group process any change might be attributed. Results of this study are therefore being used to inform further qualitative research investigating participants’ experiences of group therapy. CONTINUING EDUCATION Group therapy for school-aged children who stutter: A survey of current practices Multiple-choice self-assessment CE questions 1. Studies exploring the effectiveness of therapy for school-aged CWS: (a) are poorly designed; (b) form a compelling body of evidence supporting the use of group therapy; (c) suggest that group therapy is not effective; (d) are limited in number. 2. Our survey shows that group therapy for school-aged CWS is most frequently delivered: (a) intensively; (b) weekly; (c) monthly; (d) intensively with weekly follow-up. 3. The results of this survey indicate that a significant barrier to the provision of group therapy is:
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(a) a lack of funding; (b) health and safety issues; (c) a perceived lack of client interest in group therapy; (d) a lack of published therapy resources. 4. The clinicians in our survey were most likely to identify the following as a main aim of group therapy for CWS: (a) increasing fluency; (b) increasing confidence; (c) addressing teasing and bullying; (d) addressing affective, behavioural and cognitive responses to stuttering. 5. In large, sparsely populated areas, barriers to the provision of individual therapy for PWS have been overcome through: (a) outreach clinics; (b) telehealth; (c) SLT assistants; (d) increasing staffing levels. Acknowledgements The authors would like to thank all the SLTs who completed the questionnaire.
References Bloor, M., Horobin, G., Taylor, R., & Williams, R. (1978). ISLAND health care: Access to primary services in the Western Isles. Aberdeen: Institute of Medical Sociology, University of Aberdeen. [Occasional paper no. 3]. Boulton, M. J., Trueman, M., Chau, C., Whitehand, C., & Amatya, K. (1999). Concurrent and longitudinal links between friendship and peer victimization: Implications for befriending interventions. Journal of Adolescence, 22, 461–466. Carey, B., O’brian, S., Onslow, M., Block, S., Jones, M., & Packman, A. (2010). Randomized controlled non-inferiority trial of a telehealth treatment for chronic stuttering: The Camperdown Program. International Journal of Language & Communication Disorders, 45, 108–120. Cowie, H., Hutson, N., Oztug, O., & Myers, C. (2008). The impact of peer support schemes on pupils’ perceptions of bullying, aggression and safety at school. Emotional & Behavioural Difficulties, 13, 63–71. Crichton-Smith, I., Wright, J., & Stackhouse, J. (2003). Attitudes of speech and language therapists towards stammering: 1985 and 2000. International Journal of Language & Communication Disorders, 38, 213–234. Davidson Thompson, T. (2008). In search of best practice: Is current speech and language therapy practice meeting the psychosocial needs of adults who stutter? In 8th Oxford Dysfluency Conference. Davidson Thompson, T. C., Mcallister, J., Adams, M., & Horton, S. (2009). Evaluation and discharge criteria in therapy with adults who stutter: A survey of speech and language therapists. International Journal of Speech-Language Pathology, 11, 45–53. Davis, S., Howell, P., & Cooke, F. (2002). Sociodynamic relationships between children who stutter and their non-stuttering classmates. Journal of Child Psychology and Psychiatry, 43, 939–947. Edwards, R., Stewart, T., O’Leary, I., Williams, K., & Turnbull, J. (2005). A collaborative approach to promoting service equity for children who stutter. In 7th Oxford Dysfluency Conference. Evans, D., Healey, E. C., Kawai, N., & Rowland, S. (2008). Middle school students’ perceptions of a peer who stutters. Journal of Fluency Disorders, 33, 203–219. Franken, M. J., Van Der Schalk, C. J., & Boelens, H. (2005). Experimental treatment of early stuttering: A preliminary study. Journal of Fluency Disorders, 30, 189. Guitar, B. (2006). Stuttering: An integrated approach to its nature and treatment. Baltimore: Williams and Wilkins. Guitar, B., & Reville, J. (2003). Counseling school-age children in group therapy. In J. FRASER (Ed.), Effective counseling in stuttering therapy. Memphis, TN: The Stuttering Foundation [Publication no. 0018]. Haynes, R., Gale, S., Mugford, M., & Davies, P. (2001). Cataract surgery in a community hospital outreach clinic: Patients’ costs and satisfaction. Social Science & Medicine, 53, 1631. Hearne, A., Packman, A., Onslow, M., & Quine, S. (2008). Stuttering and its treatment in adolescence: The perceptions of people who stutter. Journal of Fluency Disorders, 33, 81–98. Joffe, V., & Pring, T. (2008). Children with phonological problems: A survey of clinical practice. International Journal of Language & Communication Disorders, 43, 154–164. Jones, M., Onslow, M., Packman, A., Williams, S., Ormond, T., Schwarz, I., et al. (2005). Randomised controlled trial of the Lidcombe programme of early stuttering intervention. British Medical Journal, 331, 659–661. Le Mesurier, N., & Duncan, G. (2000). Over the hills and far away: Providing accessible day care services for older people in rural areas. Managing Community Care, 8, 33–37. Millard, S. K., Edwards, S., & Cook, F. M. (2009). Parent–child interaction therapy: Adding to the evidence. International Journal of Speech-Language Pathology, 11, 61–76. Murphy, W., Yaruss, J. S., & Quesal, R. W. (2007a). Enhancing treatment for school-age children who stutter: I. Reducing negative reactions through desensitization and cognitive restructuring. Journal of Fluency Disorders, 32, 121–138. Murphy, W., Yaruss, J. S., & Quesal, R. W. (2007b). Enhancing treatment for school-age children who stutter: II. Reducing bullying through role-playing and self-disclosure. Journal of Fluency Disorders, 32, 139–162. Schopp, L. H., Demiris, G., & Glueckauf, R. L. (2006). Rural backwaters or front-runners? Rural telehealth in the vanguard of psychology practice. Professional Psychology: Research and Practice, 37, 165–173. Stewart, T., & Turnbull, J. (2007). Working with dysfluent children: Practical approaches to assessment and therapy. Brackley: Speechmark Publishing Ltd. Watt, I. S., Franks, A. J., & Sheldon, T. A. (1993). Rural health and health care. British Medical Journal, 306, 1358. Williams, D. F. (2006). Stuttering recovery: Personal and empirical perspectives. Mahwah, NJ, USA: Lawrence Erlbaum Associates Publishers. Yalom, I. D., & Leszcz, M. (2005). The theory and practice of group psychotherapy. New York: Basic Books. Zebrowski, P. (2007). Treatment factors that influence therapy outcomes of children who stutter. In E. G. Conture, & R. F. Curlee (Eds.), Stuttering and related disorders of fluency. New York: Thieme.
Hilary Liddle is an experienced specialist Speech & Language Therapist. She currently works for Doncaster & Bassetlaw Hospitals NHS Foundation Trust, providing a service for children and adults who stutter. She is also a part time PhD researcher at Leeds Metropolitan University, UK.
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Dr Sarah James is a qualified speech and language therapist and a senior lecturer at Leeds Metropolitan University. Sarah teaches disorders of fluency, applied psychology and evidence-based practice, in addition to supporting students in developing their clinical and professional skills. Sarah has clinical and research interests in disorders of fluency and psychological aspects of therapy practice, particularly the role of self-report. Margaret Hardman, PhD, is a Psychology Subject Group Leader at Leeds Metropolitan University, and was previously at the University of Bolton. Margaret’s PhD and current research is concerned with understanding the cultural, social and relational nature of children’s development, with particular focus on children’s collaborative learning in the primary classroom.
Contents lists available at ScienceDirect
Journal of Fluency Disorders
Group therapy for school-aged children who stutter: A survey of current practices Hilary Liddle ∗ , Sarah James, Margaret Hardman Leeds Metropolitan University, Civic Quarter, Leeds LS1 3HE, UK
a r t i c l e
i n f o
Article history: Received 28 March 2010 Received in revised form 5 December 2010 Accepted 12 February 2011 Available online 1 March 2011 Keywords: Group therapy Children Stuttering Survey
a b s t r a c t Although group therapy is recommended for school-aged children who stutter (CWS), it is not widely researched. This study aimed to explore this provision, using a postal survey which investigated the current practices of Speech & Language Therapists (SLTs) in the UK. Seventy percent of SLT services provided some group therapy, but the level of provision was variable. There was a lack of consensus on what the main aims of group therapy should be. Important barriers to group therapy provision were identified, including a perceived lack of clients’ interest in group therapy, and insufficient numbers of clients able to travel to group venues. This study enhances the profession’s understanding of the provision of group therapy for CWS by identifying patterns of service delivery and highlighting areas of need. Educational objectives: Readers should be able to: (1) Provide a rationale for the provision of group therapy for school-aged CWS; (2) Summarize the factors affecting group therapy provision for school-aged CWS; (3) Summarize the aims of therapy identified by the respondents to this survey. © 2011 Elsevier Inc. All rights reserved.
1. Introduction Group therapy is widely recommended to Speech & Language Therapists (SLTs) as an effective way of managing stuttering in school-aged children (e.g. Stewart & Turnbull, 2007). In recent years, the evidence base for intervention with young children who stutter (CWS) has increased significantly (e.g. Franken, Van Der Schalk, & Boelens, 2005; Jones et al., 2005; Millard, Edwards, & Cook, 2009). In contrast, studies exploring the effectiveness of therapy, including group approaches, for older children and adults remain more limited. Nevertheless, from a theoretical perspective, there is a persuasive rationale for offering this type of approach. By adolescence, many aspects of an individual’s life may become shaped around a negative self-image and fear of stuttering (Guitar, 2006). Addressing affective, behavioural and cognitive responses to stuttering is therefore a critical aspect of the therapeutic process when working with CWS (e.g. Murphy, Yaruss, & Quesal, 2007a). Evidence from psychotherapeutic literature suggests that group approaches may be particularly effective in addressing negative thoughts and feelings by eliminating the participant’s sense of isolation and invalidating his ‘heightened sense of uniqueness’ (Yalom & Leszcz, 2005, p. 6) CWS may have difficulty ‘fitting-in’ at school and being accepted by peers (Evans, Healey, Kawai, & Rowland, 2008), and one of the greatest challenges facing many school-aged CWS is bullying (e.g. Davis, Howell, & Cooke, 2002). Group therapy offers an opportunity for peer support which has been identified as having an important role in counteracting victimisation (Boulton, Trueman, Chau, Whitehand, & Amatya, 1999) and reducing children’s anxiety about bullying (Cowie, Hutson, Oztug, & Myers, 2008). Furthermore, Hearne, Packman, Onslow, and Quine’s (2008)
∗ Corresponding author. Tel.: +44 0113 812 5823. E-mail addresses: [email protected] (H. Liddle), [email protected] (S. James), [email protected] (M. Hardman). 0094-730X/$ – see front matter © 2011 Elsevier Inc. All rights reserved. doi:10.1016/j.jfludis.2011.02.004
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qualitative study suggests that adolescents who stutter have a strong preference for group rather than individual therapy, and Murphy et al. (2007a) suggest that group therapy can play a useful role in therapy for school-aged children. Whilst there is a strong rationale for believing that group therapy can form a useful element of therapeutic intervention for school-aged children, little is known about the level and nature of this provision or about how group therapy provision operates in practice. In other areas of stuttering research, SLTs’ practices and attitudes have been documented using surveys. These have been useful, for example, in identifying wide variations in practice (Davidson Thompson, Mcallister, Adams, & Horton, 2009) and in highlighting the need for ongoing professional development (Crichton-Smith, Wright, & Stackhouse, 2003). The aim of the present study was to explore the provision of group therapy for school-aged CWS, by investigating current practices of clinicians. 2. Method 2.1. Design The design of this study was a survey by postal questionnaire. 2.2. Procedure One questionnaire was sent to each of the 205 paediatric SLT departments in the UK. An accompanying letter requested that the questionnaire be completed by a dysfluency specialist or, where this was not possible, by another SLT in the department who had responsibility for providing a service to school-aged CWS. 2.3. Questionnaire development A questionnaire was developed and piloted. A mixed format of open and closed questions addressed the following areas of practice: 1. 2. 3. 4.
Respondent and service characteristics; Level and mode of group therapy provision; Factors affecting group therapy provision; The main aims of group therapy.
2.4. Analysis Data was analysed using SPSS (Windows version 15.0). Descriptive and inferential statistics were used to summarise information obtained and to explore factors that affect group therapy provision. 3. Results Percentage figures are reported to the nearest whole number. 3.1. Respondent and service characteristics Of the 205 questionnaires distributed, 143 completed questionnaires were returned, representing a 70% response rate. Sixty-eight percent (n = 95) of respondents reported that they were dysfluency specialists. Thirty-five percent (n = 44) of respondents reported that they served inner city/urban communities with 65% (n = 83) serving rural/mixed (rural and urban) communities. 3.2. Level and mode of group therapy provision Seventy percent (n = 100) of respondents reported that their services provided group therapy for school-aged CWS, with 70% (n = 70) of these reporting that they had provided some group therapy within the past year. The majority of group therapy was delivered on an intensive (43%) or a weekly (31%) basis. Forty nine percent (n = 61) of respondents reported that their services had accessed some out-of-district group therapy provision for school-aged CWS in the previous two years. 3.3. Factors affecting group therapy provision Inner city and urban services were significantly more likely than rural/mixed services to provide group therapy (2 (1, n = 127) = 4.11, p < .05), and specialists were more likely to provide group therapy than non-specialists (2 (1, n = 140) = 15.60, p < .001).
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Table 1 Perceived barriers to group therapy provision. Factor
% (n) of non-providers agreeing with statement
Sufficient numbers of clients are able to travel to group venues CWS have sufficient interest in group therapy Parents have sufficient interest in group therapy There are sufficient numbers of school-aged CWS to form groups SLTs are sufficiently confident in facilitating groups for CWS SLT s have undergone sufficient training to enable the provision of group therapy for CWS SLTs have sufficient experience to enable them to provide group therapy for CWS Staffing levels are sufficient to enable the provision of group therapy for CWS There is sufficient availability of suitable accommodation for the provision of group therapy SLTs are sufficiently competent in facilitating groups for CWS SLTs have sufficient interest in group therapy for CWS There is sufficient management support for the provision of group therapy for CWS
16 (6) 18 (7) 23 (9) 28 (11) 31 (12) 46 (18) 46 (18) 50 (19) 50 (20) 51 (20) 51 (20) 58 (22)
Table 2 The aims of group therapy for school-aged CWS (n = 92). Main aim of group therapy Increased confidence Fluency skills Social/communication skills Improved attitude to stuttering (e.g. desensitisation) Peer support Problem solving Knowledge/education/empowerment Cognitive skills (CBT, cognitive therapy, positive thinking) Identification of stuttering behaviour Modification of stuttering behaviour Developing specific skills (e.g. telephoning)
% (n) identifying aim 75 (69) 70 (64) 58 (53) 40 (37) 39 (36) 21 (19) 20 (18) 15 (14) 12 (11) 12 (11) 10 (9)
Perceived barriers to the provision of group therapy were explored by asking respondents to rate their level of agreement with a series of statements on a 5 point Likert scale. Table 1 shows the percentage of those participants reporting that they did not provide therapy (non-providers) who agreed or strongly agreed with each statement. 3.4. Group therapy process 3.4.1. Therapy aims Providers were asked to identify their main aims of group therapy. Responses were coded and frequency counts performed. Responses are summarised in Table 2. Chi-square analyses indicated that there were no significant differences between specialist and non-specialist providers in identified aims. 4. Discussion 4.1. Patterns of delivery The majority of respondents reported that their service provided some group therapy for CWS, although it should be acknowledged that services that provide group therapy may have been more likely to respond to the survey. A number of factors that have the potential to influence group therapy provision were identified. Results from this survey indicate that services based in inner city and urban areas are more likely to provide group therapy than those in rural or mixed areas. Research in fields, such as general medicine, has shown that distance from health service provision is negatively related to its use (Watt, Franks, & Sheldon, 1993). This may be partly due to variations in people’s inclination to access services, for example it has been shown that perceived need is inversely related to remoteness (Bloor, Horobin, Taylor, & Williams, 1978). Another possible explanation might be that sparser and more widely distributed populations make it difficult to obtain the critical numbers needed to run groups. Table 1 suggests that both of these factors may be important in non-provision of group therapy. Access to services has been improved in other health fields through the use of outreach clinics (Haynes, Gale, Mugford, & Davies, 2001), mobile day care services (Le Mesurier & Duncan, 2000), and telehealth (Schopp, Demiris, & Glueckauf, 2006). Telehealth has also been used to provide individual therapy for people who stutter (PWS) in large, sparsely populated areas, such as in Australia (Carey et al., 2010). Although these potential solutions have limited application in group therapy, telehealth may offer some benefits through the use of web based social networking sites. Another possible solution is the provision of residential courses (Edwards, Stewart, O’Leary, Williams, & Turnbull, 2005)
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A perceived lack of both parent and child interest in group therapy was identified as a possible barrier to group therapy provision (Table 1). This finding has similarities to those described by Joffe and Pring (2008), who reported that parental motivation is a factor in SLTs’ clinical decision making. It is unclear from the current study whether or not clients do lack interest in group therapy, or whether this is simply therapists’ perception. Zebrowski (2007) suggests that the clinician’s expectation of therapeutic success is an important factor in the client’s process of change. Clinician factors, such as lack of confidence (Table 1), which were found to be barriers to intervention may have therefore also impacted negatively on clients’ level of interest in group therapy or on therapists’ perceptions of clients’ level of interest. A further factor in the perceived lack of clients’ interest may have been anxiety about group therapy. Issues such as these are currently being explored, in depth, in further research involving SLTs, and CWS and their parents. 4.2. Group therapy process Therapists who took part in this study used a wide variety of aims, and overall there was a lack of consensus on what the main aims of therapy should be. Different sub groups of respondents did not use different aims of therapy, although other research, for example Davidson Thompson’s (2008) survey, has shown that specialists and generalists have different therapeutic goals for PWS. Respondents to the current survey took an eclectic approach to therapy with many individuals reporting a range of aims. It was surprising, given the issues that CWS have with sociodynamic relationships (e.g. Davis et al., 2002), that addressing teasing and bullying was not widely identified as an aim of therapy. However peer support, which is known to play a role in reducing anxiety about bullying (Cowie et al., 2008), and confidence-building, which plays a role in helping children to respond assertively to bullying (e.g. Murphy, Yaruss, & Quesal, 2007b) were widely used aims. 4.3. Recommendations for clinical practice When planning group interventions, SLTs should give careful consideration to the practicalities of group therapy provision. In particular, the needs of children and parents who might benefit from group therapy, but who may be reluctant to attend, should be addressed. For example, children could be encouraged to experience a single session of group therapy before committing to a full course of therapy. The most frequently used aim of therapy was to increase children’s self-confidence. This indicates that the need to address the underlying affective, behavioural and cognitive aspects of stuttering is widely recognised. There are a number of recommended texts which give the clinician practical suggestions about how to address these issues with children, both individually and in groups. For example, Guitar and Reville (2003), Murphy et al. (2007a), Stewart and Turnbull (2007), and Williams (2006). 5. Conclusion Although many SLTs who responded to this survey reported that their services provided some group therapy for CWS, the level of provision varied. It is important to overcome the barriers to group provision, identified by this study, or to explore alternative ways of achieving the benefits that group therapy offers. A lack of consensus on the aims of group therapy raises questions about how group therapy might facilitate change in the child’s experience of stammering, and to what part of the group process any change might be attributed. Results of this study are therefore being used to inform further qualitative research investigating participants’ experiences of group therapy. CONTINUING EDUCATION Group therapy for school-aged children who stutter: A survey of current practices Multiple-choice self-assessment CE questions 1. Studies exploring the effectiveness of therapy for school-aged CWS: (a) are poorly designed; (b) form a compelling body of evidence supporting the use of group therapy; (c) suggest that group therapy is not effective; (d) are limited in number. 2. Our survey shows that group therapy for school-aged CWS is most frequently delivered: (a) intensively; (b) weekly; (c) monthly; (d) intensively with weekly follow-up. 3. The results of this survey indicate that a significant barrier to the provision of group therapy is:
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(a) a lack of funding; (b) health and safety issues; (c) a perceived lack of client interest in group therapy; (d) a lack of published therapy resources. 4. The clinicians in our survey were most likely to identify the following as a main aim of group therapy for CWS: (a) increasing fluency; (b) increasing confidence; (c) addressing teasing and bullying; (d) addressing affective, behavioural and cognitive responses to stuttering. 5. In large, sparsely populated areas, barriers to the provision of individual therapy for PWS have been overcome through: (a) outreach clinics; (b) telehealth; (c) SLT assistants; (d) increasing staffing levels. Acknowledgements The authors would like to thank all the SLTs who completed the questionnaire.
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Hilary Liddle is an experienced specialist Speech & Language Therapist. She currently works for Doncaster & Bassetlaw Hospitals NHS Foundation Trust, providing a service for children and adults who stutter. She is also a part time PhD researcher at Leeds Metropolitan University, UK.
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Dr Sarah James is a qualified speech and language therapist and a senior lecturer at Leeds Metropolitan University. Sarah teaches disorders of fluency, applied psychology and evidence-based practice, in addition to supporting students in developing their clinical and professional skills. Sarah has clinical and research interests in disorders of fluency and psychological aspects of therapy practice, particularly the role of self-report. Margaret Hardman, PhD, is a Psychology Subject Group Leader at Leeds Metropolitan University, and was previously at the University of Bolton. Margaret’s PhD and current research is concerned with understanding the cultural, social and relational nature of children’s development, with particular focus on children’s collaborative learning in the primary classroom.