Abstract
BACKGROUND:
Despite acknowledgement by various stakeholders that therapeutic alliance (TA) is an essential component of stuttering intervention, a comprehensive understanding of this concept is lacking in the field of speech and language therapy. There continues to be a significant gap in our knowledge regarding what adults who stutter (AWS) perceive to be the qualities and activities required by both themselves and the speech and language therapist (SLT) to facilitate an effective TA. Collection of such knowledge will support the establishment and maintenance of positive TA in clinical contexts and enhance treatment outcomes for those who stutter.
OBJECTIVE:
To explore the perspectives of AWS on the meaning of TA and the variables that influence its establishment and maintenance.
METHODS:
Semi-structured interviews were completed with eight AWS. The interview questions centred on three key topics: the conceptualisation of TA through the perspective of AWS; the activities and personal qualities of the SLT that influence TA; and the activities and personal qualities of the AWS that influence TA.
RESULTS:
Reflexive thematic analysis identified two overarching themes: ‘Recognising stuttering in a biopsychosocial context in order to enhance therapeutic alliance’ and ‘Person-related variables influencing therapeutic alliance’. In addition, five subthemes were identified which further illuminated each overarching theme.
CONCLUSIONS:
Findings of this study highlight the benefit of collecting patient-based evidence to support our understanding of TA. Results demonstrate the complexity of TA in stuttering intervention, and the impact that person-related variables have on its quality.
Introduction
Stuttering is a neurodevelopmental communication difference, with symptoms presenting in early childhood (Campbell et al., 2019; Constantino et al., 2022; Yairi, 2013). Deviations from typical fluency and temporal patterns of speech can be characterised by repetitions, prolongations, and blocks, and may be accompanied by behaviours, such as eye blinking, tremors, head jerks, and respiratory changes (American Psychiatric Association, 2013; Maguire et al., 2020). Tichenor and Yaruss (2019) explored the experience of stuttering from the viewpoint of AWS and concluded that stuttering is a collection of experiences that include, but go beyond, the overt speech disfluencies. Their holistic conceptualisation of stuttering acknowledges the range of affective, behavioural, and cognitive reactions an individual may present with, as well as the implications stuttering can have on an individual’s life participation. Additionally, this study highlights the role of environmental influences, such as the response of listeners, that impact these personal reactions. Constantino et al. (2022) argue that the difficulties associated with stuttering are primarily related to social stigmatisation rather than the disfluency itself, with the internalisation of such discrimination creating a sense self-stigma. Stuttering, therefore, is a complex and individualised experience that culminates in unique impacts for the individual, many of which have negative implications in terms of life participation and quality of life.
Despite a wide range of stuttering interventions highlighted in the literature, there is no one intervention that demonstrates increased efficacy over another (Baxter et al., 2015; Connery et al., 2021). Research has identified a range of effective interventions including speech restructuring (modifying speaking style in order to reduce stuttering (Cream et al., 2010)), technology-based interventions (e.g., modifying auditory feedback), psychological interventions (e.g., Cognitive Behavioural Therapy), pharmacological approaches, and mixed approaches (Baxter et al., 2015; Botterill, 2011; Brignell et al., 2020; Connery et al., 2021). Some researchers have advocated for the influential role of factors outside the specific intervention technique on treatment outcomes. Such factors include TA, or person-related variables such as a client’s readiness for change or a clinician’s empathy (Botterill, 2011; Connery et al., 2022; Ebert & Kohnert, 2010; Grencavage & Norcross, 1990; Manning, 2000; Rodgers et al., 2021; Zebrowski et al., 2021). This prompts us to consider whether the intervention technique is the primary effective component of stuttering intervention or whether there are other factors that play a role (Connery et al., 2022). The discipline of psychology has acknowledged the importance of these additional or ‘common factors’, deeming them to be of pinnacle significance to intervention success (Flückiger et al., 2018; Messer & Wampold, 2002; Wampold & Bhati, 2004). Whilst speech and language therapy cannot be considered psychotherapy, SLTs nonetheless require psychological knowledge and skills to manage the totality of the implications of stuttering for adults. Factors outside of the therapeutic technique, in particular that of TA, remain relatively unexplored in the speech and language therapy literature, thus limiting the provision of holistic care to those who stutter (Connery et al., 2022).
In 1979, Edward S. Bordin presented a tripartite model of what he termed working alliance between a therapist and their client, which comprised of: 1) consensus on therapy goals, 2) agreement on the tasks throughout therapy, and 3) the affective bond between the therapist and client. In more recent times, TA has been described as a catch-all term for a variety of interpersonal processes and interactions co-created by the client and therapist during an intervention (Green, 2006; Walsh & Felson Duchan, 2011). An important development since Bordin’s definition is the acknowledgement that TA between the clinician and client is a relationship that continuously develops over time (Walsh & Felson Duchan, 2011). In addition, external variables that influence TA have been identified including contextual factors, e.g. limited time with clients (Lawton et al., 2018a). The importance of developing TA with additional primary care givers, such as parents, has also been highlighted (Freckmann et al., 2017).
A limited number of studies, with small participant sizes, have explored the role of TA in stuttering intervention. In a study conducted by Plexico et al. (2010), AWS defined the attributes they believed SLTs needed to create positive changes in their communicative capacities. One recurrent theme identified was that fostering a strong TA was an important factor. Participants also reported that a positive TA requires authenticity and empathy on behalf of the SLT. This is consistent with the work of Quesal (2010), who commented that a key risk factor for unsuccessful stuttering intervention is scientific dispassion and the clinician’s lack of empathy. A more recent study by Croft and Watson (2019) concluded that student SLTs associate positive TA with effective intervention outcomes. Furthermore, Sønsterud et al. (2019), found significant associations between TA and client motivation, and TA and treatment outcomes for AWS. Importantly, examination of patient-based evidence (knowledge from client experiences, e.g., a client’s intervention preferences) and practice-based evidence (knowledge from clinical experience, e.g., a clinician’s opinion) informs us that key stakeholders including AWS and SLTs believe that TA is an essential component of effective stuttering intervention, thus providing rationale for the further examination of this concept (Connery et al., 2020a; 2021; McCurtin et al., 2019).
It is essential that we increase our understanding of the establishment and maintenance of TA, from the viewpoint of key stakeholders, in order to enhance clinical practice in this area. There continues to be a significant gap in the literature regarding what AWS perceive are the qualities and activities necessary for both themselves, as the client, and for the clinician to possess in order to facilitate an effective TA. This study aims to address this gap, by collecting and synthesising the perspectives of AWS on TA.
Methodology
Research design
This study used a qualitative approach to explore the perspectives of AWS on TA in stuttering intervention. Online semi-structured interviews were used to collect the data. The study was guided by the Standards for Reporting Qualitative Research (SRQR) (O’Brien et al., 2014), a 21-item checklist designed to increase the transparency of qualitative research components. This research study received ethical approval from the Research Ethics Committee within Trinity College Dublin.
Participants
AWS were recruited for this study through the following channels: the use of international stuttering organisation gatekeepers (Appendix A), social media platforms (Appendix B), convenience sampling, and snowballing. All participants were required to meet the predefined inclusion criteria,, which were: 1) self-identification as an adult with a developmental stutter, and 2) a history of attendance at speech and language therapy as an adult for their stuttering. Exclusion criteria included: 1) adults with an acquired disfluency, 2) individuals under the age of 18 years, and 3) adults with a developmental stutter who attended speech and language therapy for stuttering only as a child. Interested participants contacted the first author and were provided with a Participant Information Leaflet (PIL). The PIL provided participants with detailed insight into the procedures of the research study. Following their agreement to complete an interview, each participant was provided with a consent form indicating their understanding of their rights regarding the study and authorisation for their interview to be audio-recorded for transcription and analysis purposes.
Table 1 summarises the participants’ demographics.
Demographic data of the participants
Demographic data of the participants
Semi structured interviews were used to collect participants’ perspectives on TA in stuttering intervention. The online conferencing platform Zoom was used to conduct and record the interviews and facilitated the involvement of international participants. Interview questions were developed by the first author and reviewed by the second author. The questions were developed following a review of the literature on TA in SLT generally, and a review of the literature relating to TA in stuttering intervention more specifically. A pilot interview was conducted in September 2022 by the first author, following recruitment using convenience sampling. Interviews were conducted in October and November 2022. They were completed at a time and date of the participants’ convenience. Each interview was coordinated, conducted, and audio recorded by the first author. Each participant was asked the same list of questions (Appendix C) and the interviewer took care to avoid leading language. Immediately following the interviews, initial impressions and conceptual ideas linked to the research aim were noted (Braun & Clarke, 2006; Braun & Clarke, 2013; Braun & Clarke, 2021). Following each interview, all audio recordings were transcribed verbatim by the first author using Microsoft Word 2022. Participants were emailed their interview transcript and were invited to member check at a time of their convenience.
Data analysis
Data were analysed using reflexive thematic analysis, an analytic technique initially discussed by Merton in 1975 and further developed by Braun and Clarke (2006; 2013; 2019; 2021). Reflexive thematic analysis was deemed the most appropriate technique for analysing the data primarily because it is a flexible, reliable, and approachable tool (Maguire & Delahunt, 2017). The process of thematic analysis is founded in the identification, development, analysis, and interpretation of recurring patterns in qualitative datasets (Maguire & Delahunt, 2017). After the primary researcher removed conversational fillers and unrelated discussion, and following participant member checking protocol, the following six measures were followed in order to complete the analysis (Braun & Clarke, 2006; 2013; 2021).
Familiarisation of the data
This stage involved gaining an intricate insight into the dataset, critically engaging with the information, and diligently noting any potential concepts and insights within the text. Each audio file was reviewed in detail to allow the first author to create a verbatim transcript. Each transcript was then read twice before the commencement of coding to facilitate familiarisation of the data. During interview completion, audio listening, and reading of the data, conceptual ideas linked to the research aim were noted (Braun & Clarke, 2006; Braun & Clarke, 2013; Braun & Clarke, 2021).
Coding
In an engaged and systematic manner, coding involved reading through each dataset and highlighting segments relevant to the research question. This allowed the first author to evolve tangible meaning organically and consistently from the datasets. Coding allowed the first author to distinguish differences within the data, whilst recognising and collating patterns, and building heuristic tools to enhance understanding (Braun & Clarke, 2006). For each complete dataset, the first author developed codes exclusively from the data, disregarding any previous knowledge of TA, thus developing a scheme grounded in the collected data alone. This step was completed by the first author and was followed by discussions with the second author to facilitate reflection and consensus on the generated codes. The authors engaged in a process of reflexivity and critical discussions during this and subsequent stages, to maintain an awareness of their influence on the data analysis (e.g. the first author considering her interpretation of the data as a final year SLT student with an interest in stuttering).
Generating initial themes
This stage involved working with the initial data codes to investigate areas with similar meanings, compiling connections, and investigating patterns further. Themes were subsequently identified by the first author through further coding of initial codes to identify similarities within the datasets (Braun & Clarke, 2006). Following the categorisation of codes, potential themes were created through pattern-based examination of the categories’ underlying meanings. These candidate themes were generated by the first author and followed by critical discussions with the second author (Braun & Clarke, 2006; 2013; 2021).
Reviewing themes
This stage involved evaluating initial themes and assessing for suitability in regard to the data. Candidate themes were reviewed in the context of the overall datasets, defining the nature of each individual theme, and the relationship between the themes. Discussions with the second author led to the collapse of themes and the separation of themes into two or more subthemes.
Defining and naming themes
Whole data sets and generated codes were further re- evaluated to verify that the final themes and subthemes represented the meaning of the data set, ensuring that they are in line with the research objectives of the present study (Braun & Clarke, 2006; 2013; 2021).
Writing up
Following the identification of themes and subthemes, the final step involved a detailed written discussion of each, including their clinical implications, clinical suggestions, and suggested areas for future research (Braun & Clarke, 2006; 2013; 2021)
Credibility and trustworthiness of the data
In order to maximise the validity and reliability of the research findings, three essential measures were taken by the authors. Firstly, each participant was provided with the opportunity to review their personal transcript and provide potential edits if desired (Birt et al., 2016). Secondly, throughout the interview process, field notes identifying initial observations and contextual factors were kept by the first author in order to support data analysis and rigour (Phillippi & Lauderdale, 2018). Thirdly, throughout the data analysis stage, ongoing discussions were had between the authors in order to achieve agreement on and to critically reflect on the meaning units, codes, and candidate themes to optimise validity.
Results
Participant information
A total of eight AWS contacted the first author agreeing to participate in the study. Participants resided in Europe (n = 6), New Zealand (n = 1), and Canada (n = 1). All participants had attended SLT for their stuttering in adulthood. Table 1 presents the participant demographics. Following feedback from the pilot interview, no modifications were made to the interview questions prior to interview commencement. The duration of the participants’ interviews ranged from 22 to 68 minutes, with a median of 44.5 minutes. Alphanumeric labels were applied to participants for the purpose of presenting the research findings.
Reflexive thematic analysis
Following the member-checking process, one participant made adjustments to their transcript which included the addition of anecdotal comments regarding their intervention experiences and therapeutic outcomes. Reflexive thematic analysis of the eight semi-structured interview transcripts generated two overarching themes and five subthemes (Table 2). Below follows a detailed description of each, supported by transcript data to demonstrate participant perspectives.
Summary of themes and subthemes
Summary of themes and subthemes
This first overarching theme, comprising of three subthemes, focuses on the participants’ desire for stuttering intervention to acknowledge and incorporate the psychological and social implications that stuttering can have on an individual, as well as its physical ramifications, in order to enhance the TA.
Subtheme: Personalised vs. Assembly-Line approach
Within this subtheme, many participants spoke about the variability of the experience of stuttering and the need for the SLT to acknowledge this. P5 commented: “I think everyone is so different and it will affect everyone in so many different ways”. Not only did several participants note the variability of the experience of stuttering amongst adults who stutter, but they also commented on the variability of their own stuttering (e.g. variability between different contexts and with different communication partners). Many participants indicated that a strong TA could be built between the client and clinician once the SLT acknowledges the variability in the presentations of stuttering. According to these participants, this can be achieved by carefully determining what each individual client’s experience of their stutter is, as well as their personal goals, and attitudes regarding their own stutter: “ . . . You should listen, and you should ask them the questions ‘what do you want from me? what do you want from yourself? How much are you going to put into this?”’ (P8).
Several participants reflected on the incongruence between the consensus that stuttering requires an individualised therapeutic approach and their actual experiences of stuttering intervention. These participants voiced how a lack of individually tailored interventions and an over-reliance on speech-orientated approaches directly impacted the establishment of a positive TA. Stuttering interventions used with many participants in the past primarily focused on reducing or eliminating the occurrence of stuttering. They reported how these instilled feelings of shame and embarrassment, and negatively impacted the establishment of a positive TA with the SLT, subsequently preventing successful intervention outcomes. P2 commented how one specific therapeutic approach (prolonged speech) caused potential risk for them to communicate in an unrealistic, pragmatically deficient manner: “ . . . the therapist would send these people out into the universe talking like drones, you know, speaking in a characteristic monotone.”. Many participants remarked that they were only able to benefit effectively from the stuttering intervention when a strong TA was formed, as the therapeutic approach could then be tailored to their stuttering experience specifically: “I just thought that when she actually knew me as me . . . then she was able to help me further.” (P5)
Many participants expressed their concern regarding the risk of SLTs falling into a pattern of utilising built-in resolutions to stuttering throughout their career, without continual professional development nor the acknowledgement of innovative research and therapeutic techniques. As P8 comments: “ . . . it will not work if the clinician goes in and says ‘I have 25 years’ experience working with people who stutter. I’ve done this”’. Participants mentioned the difficulty in connecting with an SLT who declines availing of varying approaches as they felt they were being denied their right to explore all relevant interventions available to them: “I didn’t find, for me personally, that I got any help from intervention. I felt that she didn’t really know how to handle me” (P4).
Participants relayed the value behind the SLT taking the time to get to know the person behind the stutter on a more personal level, first and foremost creating a connection of personhood. Participants felt that the initial rapport building deepens the trust between the client and clinician, and is the foundational stepping stone towards a strong, positive TA: “ . . . the therapist got to know me . . . it was very more ‘me’ centred . . . to me that was a revelation and it was brilliant . . . ” (P1). P8 described how, because each AWS brings a unique account to the intervention process, a predetermination of therapeutic measures should be avoided: “ . . . not to focus on step one . . . step two . . . step three . . . step four . . . I wouldn’t even write that chart until I had spoken to the person at least twice . . . ”. Many participants felt that the SLT should then take the opportunity to create collaborative, personal, and holistic therapeutic goals with each individual client. Many participants also discussed the significance of the SLT selecting a modern evidence-based therapeutic approach suited to the client, conducting periodic evaluations, seeking client feedback, and applying adaptations if needed throughout the intervention period. The importance of these steps is highlighted in P6’s comment: “ . . . you’re giving them the best options . . . you’re working on the basis of who you see in front of you . . . and you might have to tweak it, adapt it, and adopt different approaches . . . ”.
Subtheme: Stuttering Acceptance
Many participants communicated that the physical manifestations of stuttering are a minor aspect of the stuttering experience, with the psychological impact being identified as having the more significant impact. This is highlighted by P8: “10% is physical . . . the rest is psychological”. Despite the majority of participants agreeing that stuttering has a profound psychological effect on AWS, P6 noted the fundamental disregard for mental well-being within stuttering intervention: “None of the courses we’ve done over the years . . . mental well-being was never mentioned in any of the courses . . . it was all about your stuttering”.
When discussing the psychological elements of stuttering, most participants spoke of the significance of acceptance within the establishment of TA. Highlighted by P6’s comment: “ . . . it’s acceptance on all sides . . . ”, the interpretation of acceptance trifurcated throughout the participants’ interviews: 1. the adults’ self- acceptance of their stutter; 2. the AWS’ acceptance of intervention strategies, and 3. the SLT showing acceptance of both the stutter and personhood of the client. For example, P3 who experienced various stuttering interventions over several decades spoke about the stark difference between the interventions that were intended to ‘fix’ their stutter versus the intervention that encouraged them to accept themselves as an individual of verbal difference: “The one that kind of changed my life, probably was the therapy that I did which gave me the message that ‘it’s OK to stutter”’. P3 further commented how this was crucial in the development of a positive TA with the SLT and how this served as the foundation for successful intervention: “I would say it is one of the core values because it’s the starting point of where things can get to”.
Although self-acceptance was noted as a fundamental factor, the SLT showing acceptance of the AWS was deemed just as important in the establishment of a positive TA. Several participants spoke about the importance of the SLT accepting the individual in front of them regardless of their goals. Several participants commented that some clients may wish to gain tools for fluency, some may wish for acceptance only, whereas some may wish for both. P7 discussed the personal difficulty they found in balancing the self-acceptance of their stutter whilst simultaneously utilising fluency skills, as they felt it caused an incongruence between their thoughts and their actions: “There’s that real balance I also struggle with because . . . we’re like given these physical tools . . . but we also acknowledge that it’s so psychological . . . that idea of trying to accept yourself but work on yourself at the same time is hard”. Due to the variability of intervention goals that an AWS may arrive to therapy with, the SLT must therefore be the unwavering voice of acceptance in order to establish a positive TA. This is endorsed by P6: “if the therapist doesn’t fundamentally accept who that person is . . . yeah you’re wasting your time”.
The third and final type of acceptance conceptualises the AWS’ willingness to accept SLT intervention strategies in order to establish and maintain a positive TA. Two participants suggested that the role of the SLT was to reframe the AWS’ perspective on various speaking experiences, translating this from the clinic room to realistic circumstances. Several participants emphasised the onus on the adult who stutters to take the lead of their own intervention program, stating that the client must be prepared to accept and complete their intervention regime: “ . . . it’s the acceptance of the therapy by the stutterer” (P6).
Subtheme: Facilitating open and inclusive environments for adults who stutter
Due to the feeling of isolation that stuttering can create, outlined by P7: “The biggest thing about stuttering...and probably a lot of psychological issues . . . is the isolation”, all participants stressed how TA could be positively enhanced if a sense of stuttering community was incorporated into stuttering intervention. P5 shared how they did not encounter another individual with a stutter until early adulthood, and how that lack of camaraderie amplified feelings of loneliness. They expressed the value in receiving education regarding the stuttering community from the SLT. Furthermore, many participants expressed the importance of all individuals who stutter having the opportunity to communicate and connect with other individuals who stutter through engagement with stuttering support groups: “I do think that if individuals who stutter were exposed... to someone else who stutters and having a talk . . . it would mean an awful lot . . . ” (P5).
Some participants spoke about the potential jeopardisation that a power imbalance between the SLT and the AWS could have on the establishment of a positive TA. The meaning of this imbalance centred on feelings of isolation caused by being the only individual with a communication difficulty in the clinic room, and their feelings of vulnerability when stuttering in front of a fluent SLT who is qualified in the area of disfluency. To combat this risk, most participants spoke of their determination to incorporate group therapy sessions into stuttering intervention, to enhance that sense of community and distribute power equally: “If you have one SLT and five stutterers in the intervention room... then... all of a sudden you don’t feel self-conscious . . . but I guess that’s just humans feeling like ‘oh I’m not alone... great!’...” (P7). P3 spoke of the benefits that group diversity can bring to intervention in their comment: “The benefits of group therapy was just massive as well because like . . . your fellow course members . . . they all brought different qualities to the mix”. A further recommendation by several participants to avoid this power imbalance centred on SLTs’ completion of the practice of voluntary stuttering. These participants felt that this experience could actively strengthen the establishment of a positive TA between the client and SLT in the following two ways. Firstly, the feeling of shared experiences in stuttering intervention was noted to aid the development of TA: “We all went through the exact same thing, and we understand how it feels . . . that’s the most important part” (P5). Secondly, the SLTs’ completion of voluntary stuttering would prove that the SLT is willing to feel uncomfortable thus inspiring the AWS to feel similarly: “I know that if the therapist wants me to leave my comfort zone . . . I have to know that the therapist is willing to leave theirs” (P3). This is expressed succinctly by P7’s idea of “I’m in the trenches with you”.
Theme: Person-related variables influencing the therapeutic alliance
The second overarching theme, comprising of two subthemes, focuses on the participants’ acknowledgement of the person-related variables linked to both the SLT and the AWS that can directly influence the establishment and maintenance of an effective TA.
Subtheme: Influencing characteristics of the SLT
Empathy was deemed to be an essential characteristic for SLTs to have when establishing a positive TA with AWS. As P6 commented “You have to have empathy . . . you empathise with the person in front of you”. All participants discussed how empathy was a fundamental trait required in order to appreciate stuttering beyond the surface level. One participant, P4, recounted how empathy could have enhanced their intervention experience: “I would have liked a bit of empathy maybe . . . just to make me feel more comfortable”. Another participant, P7, explained that by the SLT placing themselves in the shoes of the AWS and acknowledging their lifetime accumulative experiences of uncomfortable speaking experiences, it may encourage them to intrinsically recognise the invisible stuttering characteristics and fundamentally have a better understanding of the stuttering experience: “You have this awareness of like ‘oh ! other people may have this life altering thing that I can’t see’ . . . and I like to think you become a nicer person”.
Active listening was also deemed a cardinal alliance building tool during stuttering intervention, as it is the inherent root of showing respect to the experiences, thoughts, and emotions of the AWS. This is highlighted by P8’s comment: “I think the biggest gift that somebody who’s going into your line of work is . . . be a listener”. Several participants described how almost all AWS have encountered an eager communication partner waiting to interrupt and finish their sentence or have been listened to half-heartedly with a blank expression. P7 explained how such behaviour on the part of an SLT would instantaneously damage any existing or potential TA. Many participants spoke of the potential value of specialised active listening training for student SLTs to support their establishment of TA: “Maybe SLTs could receive listening lessons?” (P7).
SLTs’ understanding of stuttering itself, as well as the stuttering literature, is the third and final quality AWS deemed essential to the development of a successful therapeutic partnership. P4 highlights this in their comment: “ . . . as a speech therapist dealing with a person with a stutter . . . they really need to understand what stuttering is”. P4 presented anecdotal evidence of the damage that their SLT’s misunderstanding of stuttering caused to the therapeutic relationship explaining how they did not look forward to attending their SLT sessions as they did not feel that their therapist knew how to approach stuttering intervention, how to communicate appropriately with them, nor how to set appropriate goals. P8 described the detrimental impact that their SLT’s lack of stuttering knowledge had on them during their formative years when they were unknowingly brought in for a psychological assessment during an SLT session. The misunderstanding of stuttering aetiology and the insinuations made surrounding the client’s intelligence had such a damaging effect on both P8 and their primary care giver at the time, that they were deterred from attending SLT until adulthood: “When I was about fourteen and I said, ‘Mam I’m not doing speech therapy ever again’ and she said, ‘I’m glad . . . I didn’t want you to”’.
Several participants emphasised the significant role that ongoing professional development plays in the establishment and maintenance of a positive TA: “It’s only going to work if the therapist is tuned in to what goes on in this field and who knows the recent research” (P2). P8 went on further to explain that healthcare professionals have little to no excuse for not acquiring a comprehensive knowledge of stuttering due to the ease with which all up-to-date research is now accessible thanks to the development of the internet: “Research about stuttering is out there . . . there’s so much happening and it’s at your fingertips now”.
Subtheme: Influencing characteristics of the AWS
Characteristics of the AWS were also identified as influencing the formation of a fruitful TA. P6 commented on the importance of the AWS’ honesty when forming a TA: “It’s about being open and being honest”. One participant, P4, revealed how their conditioned covert behaviours attributed to the non-establishment of a TA: “Maybe it was my fault as well . . . maybe I just didn’t open up enough . . . I hid my stutter quite a bit”. Several participants voiced that without honesty about their thoughts, experiences, and feelings, the SLT is unable to select an appropriate intervention strategy for them. As a result, the AWS will not receive the tailored help that they need, subsequently impeding the development of a TA and ultimately damaging therapeutic outcomes: “I personally think that if a person isn’t prepared to be open and honest, they’re wasting your time and they’re wasting their own time” (P6).
A readiness for change was noted as another necessary trait for the AWS to possess in order to forge a positive TA, highlighted by P1’s comment: “You have to be prepared to change”. P6 commented that a readiness for change is the sole responsibility of the AWS: “Therapy is there for a reason . . . to help you to move you on as best you can . . . but you can only do the work yourself”. Some participants stated that the AWS must approach therapy at a time that is right for them, encapsulated by P5’s comment: “They would have to make a conscious decision that they want help first”. Several participants advised that AWS must genuinely desire stuttering intervention, be willing to follow the SLT’s advice, and be prepared to complete their therapy activities accordingly. A readiness for change may also arise from a readiness to accept that stuttering does not have a quick fix: “We have to accept, there is no quick fix” (P4). P2 explained how AWS who wish to attend SLT to acquire fluent speech must also be ready to accept and psychologically adjust to their newly found fluency after a lifetime of verbal difference: “I relearned how to speak . . . I learned fluency as a second language...”.
Discussion
Findings of this study demonstrated the need for stuttering intervention to acknowledge and incorporate the physical, psychological, and social implications that stuttering can have on an individual in order to enhance the quality of a TA. Results also highlighted the important role that both SLTs and AWS play in laying the foundation for a positive TA. Furthermore, the study revealed that the quality of a TA is influenced by the interaction of person-related factors and therapeutic activities of both the SLT and AWS.
The benefits of individually tailored stuttering interventions in terms of treatment outcomes for adults is well recognised in the research literature and clinical-practice guidelines (RCSLT 2009; Manning & Dilollo 2018; Tichenor & Yaruss, 2019). This study highlights the additional benefits of individualising intervention in terms of enhancing the therapeutic alliance between the SLT and AWS. Participants highlighted the variability of the stuttering experience and the need for the SLT to acknowledge this and tailor intervention accordingly in order to foster the development of a meaningful TA. Further, participants discussed the positive implications on TA of taking a comprehensive approach to stuttering intervention i.e. avoiding a speech-only intervention path. The importance of targeting the psychosocial implications of stuttering is well evidenced by the increase in effective psychological interventions for stuttering being identified in the research arena and used clinically with the stuttering population. These include cognitive behavioural therapy (CBT) and mindfulness-based interventions such as acceptance and commitment therapy (ACT) (Beilby et al., 2012; Cheasman, 2013; Helgadóttir et al., 2014; Gupta et al., 2016; Tichenor et al., 2022).
Findings of this study are echoed by studies investigating TA in a range of other healthcare disciplines. Palmadottir (2006), who examined TA in occupational therapy, mirrored the results of this study regarding the importance of avoiding a power imbalance between the client and therapist, and tailoring intervention to the individual to support the TA. Similarly in physiotherapy, Besley et al. (2011) and more recently Miciak et al. (2018) reiterated current findings of how intervention should be personalised and how a TA should develop from an equal partnership between the therapist and client. Participants in the current study identified the importance of group therapy to distribute power equally and to enhance a sense of community. This aligns with recent research investigating the perspectives of AWS and SLTs on effective stuttering intervention, with findings demonstrating the benefits of offering AWS a variety of intervention formats, including group therapy, to achieve their goals (Connery et al. 2021).
Results of the current study highlighted the range of person-related variables that influence the development and maintenance of the TA. Participants identified characteristics they deemed essential for the SLT to possess when establishing a TA with an AWS. These included empathy, active listening, and knowledge about stuttering and the most current research in the field. A range of interpersonal characteristics of a therapist that influence a TA have been previously identified in the SLT, psychotherapy, and physiotherapy literatures. These include empathy, honesty, respect, confidence, interest, receptiveness and genuineness (Ackerman & Hilsenroth, 2003; Miciak et al., 2018; Stewart, 2022; Van Riper, 1973; Walsh & Felson Duchan, 2011). Looking specifically at the SLT literature, some researchers have identified the SLT’s personal attributes and also their clinical activities that influence the TA. For example, Fourie (2009) investigated the desired SLT qualities of a group of adults with acquired communication and swallowing disorders. Results revealed that an effective TA can be facilitated by the interaction between the SLT’s personal and professional attributes (e.g. being understanding or erudite), and their therapeutic activities (e.g. being confident or empowering). Further activities of the SLT that can positively impact a TA have been identified in the field of aphasia, including providing and receiving honest feedback, respecting the client’s past experiences, and tailoring intervention in line with client preferences (Simmons-Mackie & Damico, 2011; Lawton et al., 2018a). Participants in the current study identified the influence on TA of SLTs’ knowledge of stuttering and the most up-to-date research. Plexico and colleagues (2010) previously highlighted that AWS are more inclined to invest in a TA with an SLT they perceive as knowledgeable about stuttering interventions and the stuttering literature generally, as this facilitates clients feeling welcomed, accepted, and understood. Despite this, significant gaps in SLTs’ knowledge of stuttering have been highlighted in the research. Tellis et al. (2008), for example, found that 87.3% of a cohort of 255 SLTs did not know about the latest genetics research in stuttering aetiology. Challenges to the development of SLTs’ adequate knowledge of stuttering may be rooted in inadequacies of their SLT university training. Research has found that a significant amount of SLT graduate students complete their education without having had any clinical experience with individuals who stutter (Yaruss et al., 2017; Santus et al., 2019). Such challenges require immediate attention given the negative impact that this reduced knowledge will likely have on the TA and subsequently the treatment outcomes for AWS.
This study also highlighted the role that the AWS plays in influencing the TA. The participants highlighted how an AWS’ readiness for change is a fundamental factor in establishing a positive TA with an SLT. This finding aligns with research findings specific to aphasia, in which the readiness of the client to contribute to intervention was found to be a crucial element for establishing a TA (Lawton et al., 2018b). Findings of research conducted in other healthcare disciplines such as psychotherapy have also concluded that difficulties generating a positive TA with a therapist may result from their diminished willingness to change (Wolfe et al., 2013; Cheng & Lo, 2018). The AWS’ ability to be open and honest about their experience of stuttering, their thoughts and their emotions was also identified as influencing the formation of a positive TA in the current study. Stewart (2022) discussed how the effectiveness of the TA relies on the AWS being willing to tell their story, despite the strong emotions that it may invoke. Importantly, the SLT must also be willing to hear this story, and to sit with the emotional pain that the AWS may be experiencing (Stewart, 2022). In summary, participants in the current study emphasised the important role that the personal qualities and activities of both stakeholder groups (AWS and SLTs) play in developing and maintaining the therapeutic alliance.
Clinical implications
The results of this study contribute to our understanding of the fundamental elements of a positive TA, which is beneficial for those working with AWS in a clinical context. In order to foster a TA, SLTs are advised to select an intervention approach that best suits a clients’ personal goals. To facilitate and evaluate such a person-centred intervention program, SLTs should make use of the ICF (WHO 2001) as a foundational framework to inform and evaluate their intervention. The ICF highlights the wide range of potential intervention goals and treatment outcomes that an AWS can experience, including enhanced communication, increased psychosocial well-being, and an overall improvement in quality of life. This study’s findings also revealed the range of factors that influence the establishment of a TA including the personal traits and activities of both the SLT and the AWS. SLTs are recommended to familiarise themselves with literature from SLT and other healthcare disciplines that explores these variables in more detail. For example, SLTs delivering stuttering intervention may benefit from the fundamental recommendations outlined by Flückiger et al. (2018) for supporting TA in psychotherapeutic practice. Flückiger and colleagues emphasise the importance of collaborative goal setting, being attentive to clients’ ambitions, and responding to clients’ motivational readiness or stage of change. They also underlined the significance of forming and maintaining an emotional connection early on in the therapeutic process, all whilst being receptive to the needs and preferences of the client.
SLT stands to benefit from adopting therapeutic frameworks and tools from other disciplines in order to facilitate, enhance and evaluate TA in clinical practice. Carkhuff’s Model of Counselling (1972; 2019) is one such framework that outlines the relevant stages in creating a counselling relationship and establishing a fruitful TA. Further developed by Fuster (2005), the Model of Counselling is grouped into five subcategories: attending, responding, personalising, initiating, and evaluating. It is anticipated that treatment processes can be improved by SLTs implementing this model into their clinical practice. In addition, the process by which the quality of a TA in stuttering intervention is evaluated from a client’s perspective can be enhanced with the use of psychotherapeutic tools. The benefit of one such tool, the client-rated Working Alliance Inventory (Horvath & Greenberg, 1989; Hatcher & Gillaspy, 2006) has been highlighted as a useful tool to measure the quality and efficacy of TA in stuttering intervention (Sønsterud et al. 2019). Importantly, undergraduate and postgraduate SLT programmes need to include specialised training in areas such as counselling skills, to ensure future SLTs have adequate knowledge and skills to support their use of such tools and frameworks (Yaruss & Quesal, 2002; Connery et al., 2020a).
Further, it is imperative that SLTs reflect on and evaluate the quality of their TA with AWS. SLTs are recommended to consider the desired therapeutic qualities outlined by researchers such as Fourie (2009), such as being erudite and empathetic, when working with AWS to enhance TA. To further enhance prospective alliances with AWS, SLTs are advised to be intrinsically candid about the personal qualities they possess that may either help or hinder the development of a positive TA with their clients. The development of a TA community of practice (CoP) would encourage SLTs to reflect on their current practices around developing alliances with their clients, and better equip them to adopt new practices to enhance these alliances (Gauvreaua & Le Dorze, 2022).
Limitations
The views expressed in this study are those of a small number of individuals from a wide range of geographical regions where the delivery of SLT education and clinical services may be diverse, thus influencing the experiences and responses of participants. The findings therefore do not comprehensively reflect the perspectives of all AWS across the globe. In addition, most of the participants had spent longer periods of time in therapy (five years or more), and the study findings may therefore not adequately represent the perspectives of adults who have spent less time in therapy. Further, one specific inclusion criterion for the study was that participants had to have attended SLT in adulthood, and findings may therefore not be generalisable to adults who have not sought SLT for their stuttering. Finally, the duration of the participants’ interviews ranged from 22 to 68 minutes. This wide range may have led to some participants’ data contributing more to the study findings than others.
Areas for further research
There is a dearth of research exploring AWS’ perspectives on TA, and this aligns with the under-representation of patient-based evidence in the SLT literature more generally (Fourie, 2009; McCurtin et al., 2019). Future research should further explore the facilitators and barriers that persist in creating a positive TA in stuttering intervention. Additionally, it would be beneficial to collate the perspectives of other key stakeholders on the role of TA in stuttering intervention, such as SLTs. It is likely that the perspectives on TA differ amongst the different stakeholder groups. This study emphasised the range of person-related variables that influence the establishment of an effective TA. Future research should continue to examine client-related characteristics, such as a readiness for change, and clinician-related factors, such as empathy, in more detail. It is crucial to pursue how such factors can be incorporated into therapeutic regimes in order to strengthen TA and enhance treatment outcomes.
Conclusion
This study identified the perspectives of AWS on TA in stuttering intervention, and the faciliatory and preventative factors involved in its establishment and maintenance. These included the need for SLTs to acknowledge the biopsychosocial impact of stuttering and the need to facilitate open and inclusive environments for AWS. In addition, the importance of person-related variables of both SLTs and AWS, and how these can directly impact the development of a TA was highlighted. This study elucidates the importance of collecting patient-based evidence to support our understanding of the concept of TA, and to provide guidance to practicing SLTs on its establishment and maintenance.
Footnotes
Acknowledgments
The authors would like to thank the participants of this study for their time and willingness to share their personal experiences of therapeutic alliance. Their contributions have been invaluable in enhancing our understanding of this topic.
Conflict of interest
The authors have no conflict of interest to report.
Appendices
Appendix C. Semi-structured interview questions
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| Identified Gender:a. Femaleb. Male | 1. Do you think a positive therapeutic alliance is an important component of stuttering intervention? | 4. Do you think the adult who stutters attending therapy plays a role in facilitating therapeutic alliance? |
| c. Non-binary/third genderd. Othere. Prefer not to say | 1) a) If so, why?If no, please explain. | •4.a What activities does an adult who stutters need to do to support the therapeutic alliance? |
| •4.b Do you think that there are any specific personal qualities or traits of an adult who stutters that can support the therapeutic alliance? | ||
| Age:a. In years____b. Prefer not to say | 2. Please describe what a positive therapeutic alliance means to you. | 5. Can you think of anything that could negatively impact the establishment of a positive therapeutic alliance? |
| Country:a. You live in:____b. Prefer not to say | 3. Do you think the speech and language therapist plays a role in facilitating therapeutic alliance? | •5.a For example: does limited time with the speech and language therapist negatively impact creating a positive therapeutic alliance? |
| Have you received speech and language therapy for stuttering? | •3.a What activities should the speech and language therapist do to facilitate therapeutic alliance? | |
| •3.b What personal qualities or traits should the speech and language therapist have to facilitate therapeutic alliance? | ||
| As a child? | ||
| a. Yes | ||
| b. No | ||
| c. Prefer not to say | ||
| As an adult? | ||
| a. Yes | ||
| b. No | ||
| c. Prefer not to say | ||
| For approximately how long have you received speech and language therapy in the past? |