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ScienceDirect Procedia - Social and Behavioral Sciences 193 (2015) 209 – 216

10th Oxford Dysfluency Conference, ODC 2014, 17 - 20 July, 2014, Oxford, United Kingdom

Solution focused brief therapy with children who stutter *Alison Nicholas The Michael Palin Centre for Stammering Children, London, EC1R 0JG, UK

Abstract Historically, speech and language therapists within the field of fluency disorders have drawn on a wide range of psychological approaches when working with children, parents, young people and adults who stutter. Therapy is often an integrated approach involving traditional therapy components such as speech fluency management and social communication skills, as well as a focus on the emotional and cognitive aspects of stuttering (Cook & Botterill, 2005; Everard, 2013; Guitar, 2006; Kelman & Nicholas, 2008; Langevin, Kully, & Ross-Harold, 2007). Solution Focused Brief Therapy is a psychological approach increasingly being used by speech and language therapists working with a range of communication disorders including stuttering (Burns, 2013, 2005; Cook & Botterill, 2005; McNeill, 2013). This paper will present the key principles and techniques of solution focused brief therapy and discuss how the approach can be adapted in order to have effective solution focused conversations with children who stutter. © by by Elsevier Ltd.Ltd. This is an open access article under the CC BY-NC-ND license © 2015 2015The TheAuthors. Authors.Published Published Elsevier (http://creativecommons.org/licenses/by-nc-nd/4.0/). Peer-review under responsibility of the Scientific Committee of ODC 2014. Peer-review under responsibility of the Scientific Committee of ODC 2014. Keywords:Solution fcoused brief therapy; stutter; children

1. Introduction to Solution Focused Brief Therapy Solution Focused Brief Therapy (SFBT) was developed by Insoo Kim Berg, Steve de Shazer and their colleagues and clients at the Milwakuee Brief Family Therapy Centre in the USA in the early 1980s (de Shazer, 1985, 1988). SFBT is regarded as being different in many ways from traditional approaches to treatment as it minimizes emphasis on the problem and shifts the focus of therapy from the problem to the solution, explores a client’s preferred future, what life will be like when the problem has gone and draws on the client’s resources and strengths to realize that future (George, Iveson, & Ratner, 1999). Solution focused therapists do not focus on the nature of an individual’s presenting problem, nor do they seek to understand the cause of the problem, rather they support the client to think about their strengths and possible solutions (Milner & O’Byrne, 2002). There is therefore a fundamental belief that * Corresponding author E-mail address: [email protected]

1877-0428 © 2015 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). Peer-review under responsibility of the Scientific Committee of ODC 2014. doi:10.1016/j.sbspro.2015.03.261

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clients have what it takes to achieve their goals and the therapist’s role is to bring this potential into their consciousness. Questions are central to the solution focused approach and the expertise of the solution focused therapist is in structuring conversations and asking questions that will guide the client towards change and solutions. When working with children, therapy will need to be individualised to the child’s developmental and linguistic level in order to ensure that questions are understood and accessible. The key to engaging children in solution focused conversations is to be creative and to remember that children may be able to attend for longer periods when they are allowed to be active, to hold things in their hands and to move around (Berg & Steiner, 2003). 2. Involving parents Most if not all therapy approaches with children who stutter consider parent participation to be vital in order for therapy to be effective (Guitar, 2006; Kelman & Nicholas, 2008; Onslow, 2003; Ratner & Tetnowski, 2006; Richele & Conture, 2007). Coping with the emotions and reactions associated with stuttering is often a key issue raised by parents of children who stutter. Although this paper focuses on how to adapt solution focused techniques when working with children who stutter, parents are an integral part of the therapy process. In some instances it is more appropriate to work with parents directly, particularly for younger children, who may not yet have the cognitive or linguistic ability necessary to engage in solution focused conversations. 3. Key principles and techniques of SFBT 3.1. Problem Free Talk SFBT sessions do not begin by asking clients to describe the problem that has brought them to the session. Rather, they begin with a period of what is referred to as “problem free talk” (de Shazer, 1988). The aim is to engage with the client as a person first and to learn more about the person we are talking to (George, Iveson, & Ratner, 2006). Clients are asked about their hobbies, interests, what they enjoy doing, what they are good at and so on. This is not regarded as “idle chit chat” (Milner & Bateman, 2011, p 35) but a genuine interest to learn more about aspects of their life other than their problem and to identify their personal qualities and highlight their skills, abilities and competencies. For example, William, aged 10 years was referred because of his severe stutter. During the period of problem free talk it was established that he was a keen footballer, trained three times a week, practised in the back garden every night and had recently been given the role of team captain. In order to encourage William to reflect on his strengths and abilities, William was asked “what does it take to be a good footballer?” “why do you think you were chosen as team captain?” “what qualities do you need to be a good team captain?” Being a good footballer and a team captain involved skills and abilities which were transferable and useful when thinking about solutions to William’s stuttering. A common criticism of the SFBT approach is that problems are avoided or a client’s concerns are minimized. While discussion of a client’s problem is not considered necessary within the solution focused approach, it is recognized that it may be an important part of the process for the client. Clients will therefore be given the opportunity to discuss their problem, however the therapist’s focus is on asking questions that encourage “change talk” or “solution-talk” rather than “problem talk” (de Shazer, 1988).

3.2. Establishing a goal A defining characteristic of SFBT is goal setting. It is important that a client’s goals are clear so that both the client and therapist have an understanding of the direction of therapy and when progress has been made. Clients may be asked, “So what are your best hopes from our talking together?” (George et al., 1999, p13). It is common for clients to describe their goals negatively, as the absence of problems. For example, “I won’t be stuttering any more”; “my stutter won’t be stopping me from talking”. The therapist’s role is to support clients to frame their goals in

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terms of the presence of solutions (George et al., 1999). For example, “I will be more fluent”; “I will be saying what I want to say”. Studies have shown that children who stutter develop negative attitudes towards their speech from a young age (Vanryckeghem, Brutten, & Hernandez, 2005) and when asked about their best hopes from therapy they are able to say what they would like to see different in their talking. 3.3. Elaborating best hopes or preferred future Once a client’s goals are established, a series of questions are asked to enable them to describe their best hopes or preferred future in detail, to describe what their life will be like when the problem has gone. The details are important as the clearer a client is about their preferred future the more likely it is that it is achieved (de Shazer, 1994). The therapist will need to support clients to describe their best hopes in positive, concrete, realistic ways and to include the perspective of others, a description of their responses and in turn the effect these have on the client (Ratner, George, & Iveson, 2012) Discussing life without the problem can be highly motivating for clients and describing and imagining life without the problem has the potential to bring that life into being. There are a number of ways of supporting clients to describe their best hopes and traditionally has involved the ‘Miracle Question’: “Suppose that after we talk today, you go home and when you fall asleep tonight a miracle happens…all the problems that have brought you here today have disappeared…but because you are asleep you don’t know that the miracle has happened….When you wake up in the morning how will you know the miracle has occurred?...what will be the first sign which will tell you that the miracle has happened?” (de Shazer, 1988). Alternatively clients may be asked a less dramatic, “Tomorrow Question” (George et al., 1999; Ratner et al., 2012) where they describe life when their best hopes are achieved “Let’s imagine you wake up tomorrow and your hopes are achieved. What will you begin to notice? Who else will notice that you’re doing something different? How might he/she respond? And if they did that, how will you respond to them?” For clients who stutter this may be the first time they have considered in any detail the implications of being fluent, the impact that this may have on their life and how life will be different when their best hopes of fluent speech has been realised. For children who stutter the “Miracle Question” can be presented with a prop like a fairy godmother or a magician who waves their magic wand or gazing into a crystal ball to help them imagine their problem disappearing. Drawings are also valuable in supporting children to describe their preferred future and construct what this would look like. For example, George, an 8 year old boy who stutters described his best hopes as being able to answer more questions in class. He found it hard to sit and talk about this but was happy to draw a picture and talk about what his picture meant. He showed an understanding of what “being confident” meant to him and by talking in detail about what he would be doing, how he would be feeling, what others would be noticing helped George to see that asking more questions in class was possible.

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Fig. 1. Best hopes drawing Younger children who stutter can also be supported to describe their best hopes using role play. Acting out or pretending to do something is almost the same as doing it (Milner & Bateman, 2011). For example, the parents of Omar, aged 6 years were concerned that Omar’s late bedtime and subsequent tiredness was having an impact on his stuttering. They were finding Omar’s behaviour at bedtime challenging and he was going to bed later and later. Omar was keen “to be good” at bedtime but needed support in knowing how to do “being good”. By setting the clinic room up as his bedroom, Omar was able to actively demonstrate what being good at bedtime would involve “I’ll be having a bedtime story with Mum”, “I will be climbing into my bed and turning my night light on” “I will lie in bed until I fall asleep” and so on. Omar’s parents contributed to the elaboration of Omar’s best hopes by adding what they would notice about Omar when the bedtime routine was going well. 3.4. Identifying exceptions or instances of success Within SFBT all problems, however entrenched, are regarded as having exceptions, times when the problem could have happened but it did not or it happened less (de Shazer, 1985). George et al. (1999) place emphasis on what the client is already doing that might help them achieve the solution, seeking out “instances” when the client’s best hopes or preferred future is already being realised. Looking for these exceptions to the problem or instances of success are central to the solution focused approach. These exceptions or instances often go unnoticed by individuals and when they are noticed, they can be quick to dismiss or minimise them or consider them as chance. By paying more attention to these exceptions and asking ‘what’, ‘when’, ‘how’, ‘when’ and ‘who’ questions therapists can explore them in more detail. This provides the individual with evidence that they have the resources, strengths and abilities to make the necessary changes, that they already have successful solutions to their problem in place and that they already know what works (Milner & Bateman, 2011). For children who stutter, there are often times when their speech is more fluent or times when they are talking confidently and not worrying about their speech. Tom, aged 10 years was a popular boy and a confident communicator with his friends. However he reported that he “hated” reading aloud in class and was becoming increasingly anxious about his transition to secondary school when he would be expected to read aloud more often. Tom benefitted from finding the exception to his experience of stuttering whilst reading aloud: “You were saying that your stutter when reading aloud is worse at the moment than it was last year in Year 5”. “Tell me about the times last year when you were able to read aloud in class”. By bringing these past successes into his awareness Tom gradually became more confident about his ability to read aloud in class.

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3.5. Scaling One of the most helpful techniques in the solution focused approach is the use of scaling questions. The client is asked to think of a scale where 10 represents their best hopes achieved and 0 represents the opposite. Scaling questions are not used as a measure the extent of a problem but rather they are used to establish where a client is on the scale in relation to their goal, to recognise the steps he or she has already taken which allows them to put themselves at that point and to identify the next small steps of change (George et al., 1999). Scaling questions can be constructed with a wide range of opposites. For example, a child who stutters may have 0 = not talking at all in class and 10 = talking as much as I would like; 0 = no confidence to put my hand up and10 = confident to put my hand up. Scaling questions work particularly well with children as they are often able to communicate easily with numbers. For children who are more active, they can write down the numbers 0 to 10 on separate pieces of paper and place them on a table. It may also be helpful to transform scaling questions into actions. Numbers can be placed on the floor from one end of the room to the other and the child can physically jump or step along to indicate where they are on the scale. You can then ask them to jump or step up one number higher and ask them what they will notice when they have moved up one point on the scale. Stairs can be used with the bottom step representing 0 and top step 10. Scaling questions can also be easily adapted to make them as child friendly as possible. Numbers can be replaced with ladders, pictures of faces, characters from the child’s favourite book or TV programme or scales can be made up of animals that represent their preferred future or shapes which start small and gradually get bigger (see Berg & Steiner, 2003). The following example demonstrates how scaling questions might be used with a child who stutters. Yusuf was very concerned about his stutter, how others would react and was therefore avoiding talking a lot of the time. On a scale of 0 to 10 with 0 being not talking at all and 10 being talking as much as you would like, Yusuf rated himself at a four. Yusuf was able to say why he had put himself at four and not lower. He said that he did not stutter all the time and that he was comfortable talking with his family as he knew that they understood about his stutter. When asked, “What will be different when your speech is at a 5 instead of a 4?” Yusuf said that he would be talking even more at home and also talking more to his friends at school. Developing this picture of the next small steps of change helped Yusuf to notice the times when he was talking more. Recognizing the importance of talking to others and the potential impact on his confidence, Yusuf’s parents identified the need for them to be interacting and talking to him more. They realised that as he had become quieter and less communicative at home so had they. Scaling questions can also be used to measure progress either from session to session or at the beginning of a block of therapy and at review appointments. 3.6. Feedback and closing Throughout a SFBT session, emphasis is placed on identifying the client’s strengths and resources and paying particular attention to what clients are already doing well. It is common practice for a SFBT therapist to take a break towards the end of a session and to leave the room for a few minutes to reflect on what feedback they would like to give the client. Sessions typically end with the therapist acknowledging the client’s problem, validating what the client is already doing well and reflecting on the skills, qualities and strengths that have become apparent during the session which relates to their preferred future (Ratner et al., 2012). 3.7 Follow-up sessions Noticing progress and success is an important skill in solution focused practice and follow-up sessions begin by asking, “what have you been pleased to notice since I last saw you?” or “what’s better since we last met?’ As with exceptions, signs of improvement often go unnoticed and when they are noticed, clients are quick to dismiss or minimise them. When clients describe any signs of improvement, they are asked to describe these changes in as much detail as possible with ‘what’, ‘where’, ‘when’, ‘who’ and ‘how’ questions. Clients are encouraged to congratulate themselves on their success, to reflect on what they did that led to the change (‘how did you do that?”)

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and to name the associated strength or skill involved in their achievement (“what did it take to do that?). The more able a client is to reflect on their successes and what it involved the more likely they are to do it again (Ratner et al., 2012). Being creative is again central to supporting children who stutter to discuss what has been better since their last session. For example for every sign of change that they identify a child may stack bricks one on top of the other or place beads on a string; an outline of a child’s hand can be drawn and a sign of change written in each finger. Children often like generating lists and a flipchart can be used to write down what they have been pleased to notice since their last session. Older children can write down the ideas themselves. Parents will also play a key role in noticing positive behaviours and signs of improvement and will be asked to highlight the progress a child is making at home between therapy sessions. Parents may set up a reward system involving stars, points or putting marbles in a jar and so on. Although the majority of clients are able to report that something is better, however small, some clients will respond to what’s been better since we last met by saying things are the same or saying things are worse. It is important to listen to this, acknowledge how they are feeling, ask coping questions (‘what has got you through this week?’) and then move the conversation on to what else may need to be in place for them to move forward and reach their goal. 4. Evidence for SFBT SFBT has been widely used across a range of contexts and client groups with many effectiveness studies focusing on the use of the approach in dealing with family problems, mental health problems and problem behaviours in both school and family contexts (Corcoran & Pillai, 2007; Franklin, Trepper, Gingerich, & McCollum, 2011; Gingerich & Peterson, 2013; Kim & Franklin, 2009). The most comprehensive and up to date review of the use of SFBT with children and families has been carried out by Bond, Woods, Humphrey, Symes and Green (2013). This systematic review found preliminary evidence for the effectiveness of SFBT in improving children’s internalizing (anxiety, low self-esteem and depression) and externalizing behaviour problems (aggression, oppositional behaviour and social adjustment) both in the school context and with their families. In addition, a number of methodological weaknesses were identified and the need for further high quality research was recommended to establish the effectiveness of SFBT particularly as an intervention in its own right and with children and young people with more complex profiles of need. SFBT is increasingly being used in stuttering therapy, particularly with adolescents and adults who stutter (Burns, 2005, 2013; Cook & Botterill, 2005; McNeill, 2013) and there is a clear need to evaluate its effectiveness with this client group. 5. Why use SFBT with children who stutter and their parents? For clients who stutter the desired outcomes of treatment will differ from client to client depending on their individual needs. By asking clients what they hope to gain from therapy and asking them to elaborate on their best hopes, clients broaden their perspective of what they hope to gain from therapy. When a child or parent identifies fluency as their goal they are encouraged to consider and notice what life will be like when they are more fluent. This may include change in the child’s attitude towards their speech or a change in their ability to communicate in different speaking situations. This helps a client to shift their focus away from fluency alone and to envision a broader future with a clear and detailed picture of how their life will be when things are better. Change, particularly positive change is considered inevitable within solution focused therapy (de Shazer, 1985). It is therefore a positive approach and conveys an optimism that the problem can be solved and progress will be made. The therapist communicates a sense of hope which has long been recognised as an important component of psychological growth and change (Yalom, 1995). When considering what factors might influence a child’s responsiveness to stuttering therapy Zebrowski (2007) has highlighted the important contribution of both the client’s and therapist’s expectation for success (hope) to successful therapy outcome. As solutions to a client’s presenting problem are constructed using the client’s own resources, the SFBT approach builds a client’s confidence and provides then with evidence that they have knowledge, resources, strengths, skills

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and abilities to make the necessary changes in their life. With this perspective, the child and parent are encouraged to take responsibility for change and develop their internal locus of control which has been found to be an important factor in maintaining progress following stuttering therapy for adults who stutter (Craig, Franklin, & Andrews, 1984; De Nil & Kroll 1995). Furthermore SFBT attempts to boost children’s resilience, to enable them to cope with what life throws at them, to pick themselves up and get on with life (Beasley, Thompson, & Davidson, 2003; Milner & Bateman, 2001). Studies have shown that children who stutter as young as three or four years of age develop negative attitudes towards their speech, which has important implications for their emotional wellbeing (Vanryckeghem et al., 2005). In addition, stuttering has the potential to elicit negative peer responses and affect social interaction as early as the pre-school years and school-aged children who stutter commonly experience teasing and bullying by their peers (Blood, Boyle, Nalesnik, & Blood, 2010; Ezrati-Vinacour & Levin, 2004. Langevin, Packman, & Onslow, 2009). By adolescence and adulthood, there is a high co-occurrence of stuttering and anxiety disorders (Menzies, Onslow, & Packman, 1999; Messenger, Onslow, Packman & Menzies, 2004). It is therefore important that therapy for children who stutter builds emotional resilience and coping skills as well as focusing on developing a child’s speech fluency. 4. Conclusion SFBT is an important addition to therapy with children who stutter and their parents. It can be used alongside routine assessment and therapy programmes and also used in its own right throughout a therapy session when appropriate. It enables therapists to work collaboratively with parents and children to develop a shared understanding of their personal goals from therapy and what life will be like when their stutter is no longer a problem. Creativity is a critical component of using the approach with children who stutter. By being more creative therapists can engage children of all ages in solution focused conversations and activities, to establish their best hopes, to ask scaling questions and to help them identify their strengths and what they are already doing that is helpful. Children who stutter may be aware of their speech difficultly from a young age and are able to provide some information about what they would like to see different in their talking. SFBT provides the therapist with an additional tool to work with this heterogeneous client group, facilitating individualized, client-led and optimistic intervention. Acknowledgements The author would like to acknowledge the children, young people and their families at the Michael Palin Centre who have inspired and taught us, as well as the team of therapists, the trustees of Action for Stammering Children and NHS Whittington Health. References Beasley, M.K., Thompson, T. & Davidson, J.A. (2003). Resilience in response to life stress: The effects of coping style and cognitive hardiness. Personality and Individual Differences, 34, 77-95. Berg, I.K. & Steiner, T. (2003). Children’s solution work. New York: W.W. Norton. Blood, G. W., Boyle, M. P., Nalesnik, G. R. & Blood, I. M. (2010). Bullying in children who stutter: Speech-language pathologists’ perceptions and intervention strategies. Journal of Fluency Disorders, 35, 92-109. Bond, C., Wood, K., Humphrey, N., Symes, W. & Green, L. (2013). Practitioner review: The effectiveness of solution focused brief therapy with children and families: A systematic and critical evaluation of the literature from 1990-2010. Journal of Child Psychology and Psychiatry, doi:10.1111/jcpp.12058. Burns, K. (2005). Focus on solutions. A health professional’s guide. London: Whurr. Burns, K. (2013). Changing minds, changing lives. In P. De Jong and I. Berg (Eds), Interviewing for solutions (4th Edition) Belmont, CA: Brooks/Cole. Cook, F., & Botterill, W. (2005). Family-based approach to therapy with primary school children: “throwing the ball back冾. In R. Lees and C. Stark (Eds.). The treatment of stuttering in the young school-aged child. London: Whurr. Corcoran, J & Pillai, V. (2007). A review of the research on solution focused therapy. British Journal of Social Work, 39, 234-242.

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