A Preliminary Examination of SSMP Participants' Retrospective Self-Ratings of Changes in Attitude, Communicative Abilities, and Self-Acceptance

The Journal of Stuttering Therapy, Advocacy & Research A Preliminary Examination of SSMP Participants' Retrospective Self-Ratings of Changes in Attitude, Communicative Abilities, and Self-Acceptance Author: Sandra A. Cullinan, MS CCC-SLP, Co-Editors: Gregory Snyder, Ph.D., and Peter Reitzes, MA CCC-SLP Abstract Participants of the Successful Stuttering Management Program (SSMP) from the years 1994 through 1999 were surveyed to examine their changes in communicative abilities and attitudes toward stuttering over time. Preliminary results from the pilot data indicated that while some relapse was evident in areas such as fear of certain sounds, words, and speaking situations, self-ratings in all other areas of communicative ability and attitudes toward stuttering showed a minimal decline over time. Differences between retrospective pre- and post-therapy self-ratings were significant. This study further proposes participants' self-ratings as a valid measure of stuttering treatment efficacy. Introduction The efficacy of fluency shaping versus stuttering modification approaches to the treatment of stuttering has long been debated (Reitzes, 2006; Shapiro, 1999). Fluency shaping emphasizes talking more fluently (Manning, 2000, Guitar, 1998) or stuttering less frequently (Reitzes 2006) while stuttering modification strategies focus on stuttering less abnormally and with less effort (Bloodstein, 1995, Dell, 2000). Integrated or eclectic approaches to stuttering treatment focus not only on the mechanics of speech, but also seek to reduce the consequences of stuttering by combining elements of fluency shaping and stuttering modification with the exploration of feelings and attitudes (Langevin & Boberg, 1993; Montgomery, 1997; Guitar, 1998; Starkweather & Givens-Ackerman, 1997). Bloodstein (1995) suggests that a successful and complete therapy program should demonstrate not only a reduction in stuttering behaviors, but should also address the fear and anticipation of stuttering as well as pertinent consequences of stuttering such as the person's self-concept. As a consequence of stuttering, many individuals demonstrate fears of speaking; low self-esteem; shame; word, sound, and situational avoidances; and difficulty performing communicative activities necessary for certain careers (Yaruss & Quesal, 1999). While the consequences of stuttering are clearly much more than what you hear, the results of stuttering treatment programs are often judged and evaluated in terms of pre- and post-treatment measures of audible and quantifiable moments of stuttering. Blomgren, Roy, Callister, & Merril (2005) report: Evidence-based treatments, based on well-researched and scientifically validated techniques, remain relatively rare in the field of stuttering and are usually limited to behavioral and fluency shaping

Cullinan, Snyder & Reitzes / Journal of Stuttering, Advocacy & Research, 1 (2006) 42 63 43 approaches (e.g., Boberg & Kully, 1994; Craig et al., 1996; R. J. Ingham et al., 2001; Onslow, Costa, Andrews, Harrison, & Packman, 1996). (p. 509) Opinions vary as to the value of quantitative measurements, yet insurance companies often require documentation as to the effectiveness of treatment regarding the frequency of audible stuttering behaviors (Yaruss & Quesal, 1999; Langevin & Boberg, 1993). Cooper (1997) explains that an arbitrarily selected frequency-of-fluency rate may be established as the end goal of therapy. He explains, "In addition to being impossible to attain, such goals focus the individual's attention on a variable that has little relation to the complex syndrome of attitudes, behaviors, and feelings that constitute fluency disorders" (p. 364). A model for describing the consequences of speech, language and hearing disorders has been described in a three-part classification scheme by the World Health Organization (WHO) (Curlee, 1993; Yaruss, 1998; Yaruss & Quesal, 2004). This model, the International Classification of Impairments, Disabilities, and Handicaps (ICIDH), comprises three separate but related levels that define the consequences of diseases and disorders on the physical body (impairment), the person (disability), and the person as a social being (handicap) (Badley, 1993; Yaruss, 1998; Yaruss & Quesal, 2004). The consequences of stuttering cover the broad spectrum of how the disorder affects an individual's ability to conduct life activities (Yaruss, 1998; Yaruss & Quesal, 2004). This study presents the preliminary results of a pilot survey developed within the ICIDH framework of the consequences of the disorder of stuttering in mind. The pilot survey was administered to participants in the Successful Stuttering Management Program (SSMP), an intensive, residential stuttering modification treatment program. The SSMP addresses the negative and counterproductive feelings and attitudes that often accompany stuttering while also providing participants with techniques to manage speech disruptions. This study attempts to determine what long-term effects this residential treatment program had on their attitudes toward themselves as speakers and their ability to deal with the consequences of stuttering in their daily life activities. It also examined the difference in relapse rates, over time, since attending the SSMP. It should be noted that data and results from this study offer a preliminary analysis of select aspects from SSMP participants retrospective self-rated changes in attitude, commutative abilities, and selfacceptance. Specifically, the survey itself was not tested for validity or reliability, and the statistical analysis could have benefited from the use of more complex procedures. And as is the nature of all survey data, it is unknown if the experiences of those that responded is representative of the targeted population. Despite these issues, the data reported herein offers an intriguing look at the experiences of many SSMP participants. SUCCESSFUL STUTTERING MANAGEMENT PROGRAM Philosophy and Workshops The SSMP is designed as an intensive, residential program for the treatment of stuttering as well as an intensive learning experience for students in the speech pathology program at Eastern Washington University, in Cheney, Washington. In 1998, a second SSMP workshop was started at the University of Utah, Salt Lake City. Upon entering the workshop, the clients are referred to as "stutterers." The more politically correct "person who stutters" (Guitar, 1998; Shapiro, 1999; Starkweather & Givens- Ackerman, 1998) is briefly addressed and left behind. The SSMP focuses on the acceptance of

44 Cullinan, Snyder & Reitzes / Journal of Stuttering, Advocacy & Research, 1 (2006) 42 63 stuttering, desensitization to stuttering, elimination or reduction of avoidance behaviors, becoming responsible for managing one s own stuttering, using stuttering modification speaking strategies to initiate speech and move forward through moments of stuttering, and learning about stuttering (Breitenfeldt & Lorenz, 2000). A major and fundamental component of the SSMP consists of practicing and using speaking strategies outside of the clinic in real world speaking environments (Breitenfeldt & Lorenz, 2000). The SSMP follows the Van Riper approach of motivation, identification, desensitization, variation, approximation, and stabilization (MIDVAS) (Van Riper & Erickson, 1996). The first half of each SSMP workshop focuses on "letting out" one's stuttering in an array of speaking situations. The stutterers are instructed to drop all avoidance, substitution, and secondary behaviors, thus allowing their core stuttering to surface. Participants are also instructed to advertise their stuttering (tell others that they stutter) as much as possible. For example, a participant may approach a clerk at a store and say, Exxxxcuse me, I am a ssssstutterer. Could you please tell me when your store closes? Because of the variability of stuttering (Starkweather, 1987), some participants in SSMP workshops may experience days in which they stutter very little. In these situations, such participants may be instructed to use voluntary stuttering. The second half of the SSMP is devoted to learning and then applying "handling techniques" outside the clinic environment. The three techniques taught are cancellations, pull-outs, and prolongations. "Negative practice," or voluntary stuttering, is also encouraged, as is creating a "stutterable environment" by openly advertising to listeners that one is a stutterer (Breitenfeldt & Lorenz, 2000). The SSMP consists of four hours of direct therapy with the student clinicians each weekday. The hours outside of the clinic are spent doing "home assignments" developed specifically for each client by their clinicians. These assignments generally consist of telephone calls and public conversations with strangers, focusing on each participant s individual challenges. For example, if an SSMP participant reports avoiding shopping because of the fear of stuttering in front of store employees, this participant would be assigned tasks such as using voluntary stuttering and pull-outs in stores and other public locations. Weekends are spent completing various telephone and real world speaking assignments. The overall feel of the SSMP is of a stuttering boot camp in which supervisors and clinicians assign many tasks for participants to complete each day. Clinicians must be willing to demonstrate any assignment given upon the participant s request. This insures that all assignments are reasonable (Breitenfeldt & Lorenz, 2000). Clients are videotaped three times during the program: the first day, after approximately the first week and a half, and during the final graduation ceremony. These tapings include both spontaneous speech and reading samples. Two attitudinal surveys, developed at the SSMP, are administered at the beginning of the program, the Stuttering Questionnaire and the Attitude Scale for Stutterers. The SSMP strongly emphasizes to participants the importance of maintaining changes in attitude and the use of handling techniques to move forward in speech. After completing the three and a half week program, each participant devises his or her own maintenance program. These assignments include calling other participants, clinicians, and local businesses, scheduling real world assignments, joining a support group, and educating others about stuttering. After approximately 5-6 months, participants return to attend a weekend refresher session. The refresher course mirrors the last few days of the original program, with telephone work and real world activities.

Cullinan, Snyder & Reitzes / Journal of Stuttering, Advocacy & Research, 1 (2006) 42 63 45 Frequency data are not collected at the SSMP. The founders of the SSMP believe that stuttering is too variable of a disorder and influenced too heavily by internal and external circumstances for these measures to be of any value (Breitenfeldt & Lorenz, 2000). The attitudinal surveys are used by the clinicians in the assessment process. Though it has been running for over 35 consecutive summers in Cheney, Washington, little research exists on the efficacy of the SSMP. Two reviews (DeNil & Krol, 1996; Ham, 1996) discuss the structure of the program and he SSMP manual (Breitenfeldt & Lorenz, 1989) was reviewed by Manning (1990). One outcome study (Breitenfeldt & Girson, 1995) compared changes in attitudes, secondary behaviors, and speech of participants in an SSMP workshop in Washington with participants in an SSMP workshop introduced in Johannesburg, South Africa. Results showed improvement in all three areas upon completion of the workshop yet no follow-up data was presented. A second outcome study of the SSMP by Eichstädt, Watt, & Girson (1998) found, The general trend was a decline in the maintenance of speech behaviors, with good maintenance of attitude gains 2 years post workshop (p. 231). Blomgren et al. (2005) employed a multidimensional approach to study treatment outcomes of the SSMP which included 14 fluency and emotionally based measures. Data from the Blomgren et al. (2005) study revealed that the SSMP produced sustained improvements in the areas of self-perceived avoidance and expectancy, as well as psychic and somatic anxiety (Reitzes & Snyder, in press). Blomgren et al. also report that the SSMP was ineffective in reducing core stuttering behaviors even though the authors note that such a goal is inconsistent with the values and intentions of the SSMP. Alternatively, Reitzes & Snyder (in press) suggest that a valid goal for some participants of stuttering modification based therapies such as the SSMP is to increase the frequency of stuttering in an effort to decrease speaking fears and reduce covert stuttering behaviors (Manning, 1999a, 1999b, 2000, 2003; Starkweather, 1999; Starkweather & Givens-Ackerman, 1997; Yaruss, 2001; Yaruss & Quesal, 1999). Consequently, it has been suggested that the quantification of overt stuttering frequency as a qualitative therapeutic metric is inappropriate relative to the SSMP, or any other therapy based on stuttering modification (Reitzes & Snyder, in press). METHOD Participants Participation in this study was offered to attendees of the SSMP in Cheney, Washington, from the years 1994 to 1999, and those attending the SSMP in Salt Lake City, Utah, during the summers of 1998 and 1999. Procedure A self-administered, five-page survey was mailed to all participants. (A copy of the survey is included in Appendix A.) The survey contained 30 items addressing the areas of maintenance, communicative abilities, and changes in attitude; the survey questions used terminology known to the SSMP participants. Ten questions were scaled using a five-point likert scale from "not improved at all" to "completely improved" based on a study of improvement and regression by Prins (1970). Another three questions ask the participants to rate their own speech on a 5-point likert scale ranging from "mild" to "severe." RESULTS Sixty-eight surveys were mailed to people who participated in the SSMP during the years 1994 to 1999; participants ranged in age from 14 to over 45 years (Figure 1). Of the 68 surveys mailed out, 36 (53%) were returned and analyzed. Four surveys were returned due to inaccurate address information,

46 Cullinan, Snyder & Reitzes / Journal of Stuttering, Advocacy & Research, 1 (2006) 42 63 and one person responded that he did not care to participate in the survey. The SSMP began a second workshop in 1998 in Salt Lake City, Utah, thereby increasing potential participants from the years 1998 and 1999. Table 1 details the number of participants in each SSMP workshop and the number of people from each workshop who participated in the survey. Table 1. Number of potential and actual respondents to SSMP survey from each year. Workshop Year Number of participants in that year s workshop 1994 8 1 (13%) 1995 10 4 (40%) 1996 8 4 (50%) 1997 8 5 (63%) 1998 16* 10 (63%) 1999 18 * 12 (67%) TOTAL 68 36 Number of participants in survey from that year * includes participants from both Cheney, Washington and Salt Lake City, Utah, workshops Respondents to the survey were asked which of the two main focus areas of the SSMP (use of handling techniques and changes in attitude toward stuttering) has affected them the most since leaving the program. Eight percent responded that handing techniques have affected them the most, 53% reported that changes in attitude have had the most affect, and 39% reported that both techniques have affected them equally (Figure 2). When asked which of the three handling techniques - prolongations, cancellations, or pull-outs - they used the most, 87% responded that they use the prolongation technique the most, 10% reported using pull-outs, and 3% reported using cancellations most frequently. Three respondents checked more than one technique and none of the respondents checked, "I do not use handling techniques." In response to question 7, "I feel that I now have the necessary skills to control my speech..." 6% of the respondents checked "all of the time," 56% checked "most of the time," 36% checked "some of the time," and one respondent (3%) checked "seldom." One respondent checked both "most of the time" and "some of the time" and wrote in "situational." One respondent did not answer the question, but rather, wrote in, "It's not about skills." Twenty-six respondents (72%) reported that they have not received additional speech therapy since attending the SSMP (question 8), while 10 (28%) reported that they have received additional speech therapy. When asked to briefly describe the therapy, most respondents gave the frequency (weekly to monthly). Five of the 10 reporting "yes" specified that their therapy was a continuation of SSMP-based therapy. Questions 9 through 13 addressed the role of maintenance. In answer to question 9, 12 (33%) of the respondents reported that they attend a support group for stutterers monthly, two respondents (6%) attend a group bimonthly, five (14%) reported attending a group less than once a month, and 17 (47%) of the respondents reported that they do not attend a support group specifically for people who stutter (Figure 3).

Cullinan, Snyder & Reitzes / Journal of Stuttering, Advocacy & Research, 1 (2006) 42 63 47 Question 10 asked how frequently the participant advertises that he/she is a stutterer, a practice which is emphasized throughout the SSMP. Eight (22%) respondents reported that they always (at least once a day) advertise, 11 (31 %) reported that they advertise frequently (once or twice a week), 12 (33%) reported they occasionally (once or twice a month) advertise, and the remaining five (14%) reported that they never advertise they are a stutterer (Figure 4). Question 11 asked how strictly the stutterer followed the maintenance plan that they wrote for themselves before leaving the SSMP. Thirteen (36%) respondents reported that they followed their maintenance plan exactly, 10 (28%) reported that they did about one-half of the items on their plan, 7 (19%) reported that they did about one-third of the items on their plan, and the remaining 6 (17%) reported that they did not follow their maintenance plan at all (Figure 5). Respondents who reported that they completed one-half or less of their maintenance plan were asked to respond to question 12, which gave a choice of potential reasons why the plan was not followed. While many respondents gave more than one reason why they did not follow the maintenance plan, the majority checked, "I did not have the time or make the time." One respondent from a 1999 workshop checked this response and then wrote, "but I have not experienced this as detrimental." The second most frequent reason was, "Some of my old speaking fears started to come back." One respondent wrote in the "Other" line, "I used other forms of practice." Question 13 asked how often the individual continues to give him/herself additional speaking assignments outside the required telephone calls, conversations, etc. of their everyday life. Eleven (31 %) respondents reported that they frequently gave themselves speaking assignments. When asked how often they operationally defined "frequently", the responses ranged from daily to 2 or 3 times per month. Seventeen (49%) reported occasionally giving themselves additional speaking assignments; the respondents' definitions of "occasionally" ranged from daily (one respondent) to monthly. The remaining eight (22%) reported that they never give themselves additional speaking assignments. A retrospective comparison of the respondents' mean self-ratings of their speech before attending the SSMP (question 14), speech on the final day of the SSMP (question 15), and current speech (question 16) is presented in Figure 6. A preliminary analysis of the data utilized a series of T-test pairwise comparisons, which revealed a significant difference between the overall (combined years) responses to "rate your speech before attending the SSMP" and "rate your speech on graduation day" (t = -11.79, p<.01). Significant differences were also found between the responses to "rate your speech on graduation day" and "rate your speech today" (t= 5.6, p<.01), and "rate your speech before attending the SSMP" and "rate your speech today" (t= -6.49, p<.01). Pairwise comparisons for eight pairs of questions are summarized in Table 2. A retrospective comparison of the mean self-ratings relative to the ability to communicate in school or job upon graduating from the SSMP and now (questions 17 and 18) and acceptance of self on graduation day and now (questions 19 and 20) are presented in Figures 7 and 8, respectively. Table 2. Pairwise comparisons of mean responses to survey questions. Survey Questions Compared 14. How would you rate your speech before you attended the SSMP? 15. How would you rate your speech on graduation day at the SSMP? t-value -11.79* 15. How would you rate your speech on graduation day at the SSMP? 16. How would you rate your speech today? 5.6*

48 Cullinan, Snyder & Reitzes / Journal of Stuttering, Advocacy & Research, 1 (2006) 42 63 14. How would you rate your speech before you attended the SSMP? 16. How would you rate your speech today? -6.49* 17. When I first left the SSMP, my ability to communicate in my job or at school had: 18. Now I feel that my ability to communicate in my job or at school has: -1.97 19. When I first left the SSMP, my acceptance of myself as a stutterer had: 20. Now I feel that my acceptance of myself as a stutterer has: -0.96 21. When I first left the SSMP, my fears of certain words or sounds had: 22. Now my fears of certain sounds and words have: -3.20* 23. When I first left the SSMP, my fears of certain speaking situations had: 24. Now my fears of certain speaking situations have: -3.21* 25. Since attending the SSMP, my confidence in my ability to speak has: 26. Since attending the SSMP my general confidence has: *p <.01-1.50 Respondents were divided into two groups, 1994-1996 and 1997-1999, and a t-test for pooled variances was conducted to estimate the presence of any significant differences in the two groups' responses to the inquiries "When I first left the SSMP..." (questions 17, 19, 21, 23) and "Now..." (questions 18, 20, 22, 24) (Figure 9). A comparison of the mean responses to, "When I first left the SSMP" revealed no significant difference between the 94-96 and 97-99 groups (t= -.9312, p=.3876). A comparison of the mean responses to "Now I feel... " revealed a trend toward significant difference between the two groups (t=3.616, p=.0111). Confidence in the ability to speak since attending the SSMP was assessed through question 25. Seven (19%) felt their speaking confidence had "completely improved," 23 (64%) felt their confidence in their speaking ability had "much improved," and six (17%) of the respondents felt their confidence in their speaking ability had "improved some" (Figure 10). Respondents were also asked to rate their general confidence (question 26). Two respondents (5.5%) noted "completely improved," 26 (72%) noted "much improved," one person (2.7%) checked "improved some," six (17%) checked "improved a little," and one respondent (2.7%) noted "no improvement." Respondents were asked, if they felt improvements to their speech had regressed, how long it took before they noticed they were no longer communicating as effectively as they had been when they first left the SSMP (question 27). Two (5.5%) respondents reported experiencing no relapse, eight (22%) reported that the relapse occurred within 1 to 2 months of leaving the SSMP, 15 (42%) reported 3 to 4 months, two (5.5%) reported 4 to 6 months, and two (5.5%) reported one year. While three people did not respond to the question, other variations to the responses included, "I think it's not so much of 'no longer communicating effectively,' just the number of dysfluencies increased" from a 1998 participant; "slightly, after 2 years" (1996); "hasn't" (1997); "1 to 2 years" (1997); "literally as soon as my plane

Cullinan, Snyder & Reitzes / Journal of Stuttering, Advocacy & Research, 1 (2006) 42 63 49 touched down at my return [home]" (1999); and, from a 1999 participant, "still a high degree of improvement, I don't care about speech, I care about accepting stuttering." When asked if they attended the refresher weekend offered six months after the SSMP, all 12 of the 1999 respondents said that they would likely attend in January 2000. Twenty-one (91 %) of the remaining 25 replied that they did attend the refresher, and the other two said they did not. Thirty-one (86%) said they would attend a week-long refresher if one were available, four (11 %) said they would not attend another refresher, and the remaining person said "maybe." Survey respondents were given the opportunity to offer suggestions for improvement to the SSMP (question 30). Excerpts from these responses appear in Appendix B. Graphical representation of the data can be found in Appendix C. DISCUSSION The editors would like to reiterate that the pilot data and preliminary results from this study offer a cursory analysis of select aspects from SSMP participants retrospective self-rated changes in attitude, commutative abilities, and self-acceptance. It should be noted that the survey itself was not tested for validity or reliability, and the statistical analysis could have benefited from the use of more complex procedures. And as is the nature of all survey data, it is unknown if the experiences of those that responded is representative of the targeted population. Despite these issues, the data reported herein offers an intriguing look at the experiences of many SSMP participants. Results of this study suggest a minimal but significant relapse over time; however, therapeutic relapse was not associated with a reduction in the participants' perceived ability to communicate effectively or a significant change in attitude resulting from participation in the SSMP. The majority of the participants responded that changes in attitude brought about by the SSMP had affected them the most and all participants reported that they use at least one of the three speech handling techniques. Eightyseven percent of the survey respondents reported using the prolongation technique over cancellations or pull-outs, and over half of the respondents felt that they now have the necessary skills to control their speech most of the time. Results of a meta-analysis of 42 studies by Andrews, et al. (1980) reported that the prolonged speech technique produced some of the best results in stuttering treatment. They also reported that four techniques - prolonged speech, gentle onset, attitude, and airflow - were better in the short and long term than any other techniques (Andrews, et al., 1980). Communicative abilities in job or school showed no significant relapse over the years, nor did acceptance of oneself as a stutterer (Figures 7 and 8). An area that showed a significant change over the years was fears of certain sounds, words, or speaking situations, with a return of situational fears showing a greater increase than sound/word fears. Maintenance has been called the most important phase of the rehabilitation of stutterers (Boberg, 1982). Areas of maintenance covered by the survey included advertising oneself as a stutterer, attending support groups, following a self-devised maintenance plan, and giving oneself additional speaking assignments. While the SSMP encourages participants to start a support group in their home area if one does not already exist, the majority (47%) reported that they do not attend a support group for stutterers. In other areas, responses generally suggest that SSMP participants indicated a positive tendency to practice good maintenance habits.

50 Cullinan, Snyder & Reitzes / Journal of Stuttering, Advocacy & Research, 1 (2006) 42 63 The retrospective self-ratings of speech suggest a significant difference between speech before attending the SSMP and speech on graduation day from the SSMP, and speech before the SSMP and current speech; all such comparisons indicate a positive change. However, a comparison between retrospective self-ratings of speech on graduation day and current speech also suggest a significant difference, with data implying that a certain amount of relapse had occurred. As indicated in Figure 6, this level of relapse does not show a significant downward trend over the years, but rather a consistent self-rating of mild to moderate severity over time. When dividing the respondents into two groups (1994-1996 and 1997-1999) for comparison purposes, no significant relapse was noted between the groups' responses to inquiries related to "When I first left the SSMP." However, a difference was noted between the two groups' responses to companion inquiries asking the same question in the present tense, "Now I feel " As indicated in Figure 9, the data suggests a slight increase in ratings of improvement came from the participants of earlier workshops (94-96), rather than from the more recent participants (97-99). While most efficacy studies are based on perceptual judgments by reliable listeners and counts of words or syllables stuttered, this study proposes that a valid measure of the efficacy of a treatment program for stuttering is the participants' self-ratings of their speech, attitudes toward their speech, and overall opinion of the program. With recent research questioning the overall validity of overt stuttering frequency as a metric for rating stuttering therapies, it has been suggested that self-reported data is often overlooked in the assessment of stuttering therapy efficacy (Guntupalli, Kalinowski, Saltuklaroglu, 2006) and should be considered in evaluating a treatment approach or program (Reitzes & Snyder, in press). In comparing data from treatment for other chronic problems in health sciences, Andrews, et al. (1980) deemed stuttering therapy to be effective if the results appear more stable, less influenced by choice of outcome measure, and less likely to decay with the passage of time" (p. 303). By these criteria, and the pilot data reflecting the participants' retrospective ratings of the effects of the SSMP on communicative ability, changes in attitude, and self acceptance, the SSMP may provide effective treatment for certain aspects of stuttering for some clients. The SSMP clearly addresses the consequences of stuttering within the ICIDH model of impairment, disability, and handicap. A suggestion to aid future research would be for the SSMP to take a more active approach to maintaining up-to-date records on SSMP participants. By having current addresses may have increased the survey response rate. Threats to this study s internal validity include the lack of validity testing for the survey questions, as well as mortality. If it is assumed that a participant's success with a program like the SSMP would regress over time, the more time that elapses, the less likely it becomes that that person will participate in a survey about a program which they no longer feels is benefiting them. More responses to this survey came from the more recent SSMP participants. This could be due to either of the two previously mentioned issues: current addresses for more recent attendees and possible relapse in participants from earlier years. It is also acknowledged that twice as many subjects were available from the most recent workshops (1998 and 1999). The use of an assessment tool in real-time, that collects data before beginning the program, on graduation day, and at regular follow-up intervals would also provide valuable before and after data on changes in perception of communicative abilities and attitudes toward stuttering. Additionally, such an assessment tool may consider offering a clear operational definition of relapse, as well as partake in validity and reliability testing on the survey itself. Future research involving this survey, or other

Cullinan, Snyder & Reitzes / Journal of Stuttering, Advocacy & Research, 1 (2006) 42 63 51 likert-scale based surveys should consider utilizing an alternate statistical analysis, such as employing nonparametric statistical analysis, and controlling for type I errors relative to pairwise comparisons. References Andrews, G., Guitar, B., and Howie, P. (1980). Meta-analysis of the effects of stuttering treatment. Journal of Speech and Hearing Disorders, 45, 287-307. Badley, E.M. (1993). An introduction to the concepts and classifications of the international classification of impairments, disabilities, and handicaps. Disability and Rehabilitation, 15, 4 161-178. Bloodstein, O. (1995). A handbook on stuttering (5th edition). San Diego, CA: Singular Publishing Group, Inc. Blomgren, M., Roy, N., Callister, T., & Merril, R.M. (2005). Intensive stuttering modification therapy: A multidimensional assessment of treatment outcomes. Journal of Speech, Language, and Hearing Research, 48, 509-523. Boberg, E. (1982). Behavioral Transfer and Maintenance Programs for Adolescent and Adult Stutterers. In: Stuttering therapy: Transfer and maintenance. Stuttering Foundation of America, publication no. 19, Memphis, TN. Boberg, E., & Kully, D. (1994). Long-term results of an intensive treatment program for adults and adolescents who stutter. Journal of Speech and Hearing Research, 37, 1050-1059. Breitenfeldt, D. and Girson, J. (1995). Efficacy of the Successful Stuttering Management Program workshops in the United States of America and South Africa. In: Starkweather, C.W. and Peter, H.F.M. (eds.), Proceedings of the First World Congress on Fluency Disorders, 429-431, August 8-11, 1994. Munich, Germany: University Press. Breitenfeldt, D. and Lorenz, D. (1989). Successful Stuttering Management Program for adolescent and adult stutterers. School of Health Sciences, Eastern Washington University, Cheney, Washington. Breitenfeldt, D.H., & Lorenz, D. R. (2000) Successful stuttering management program (SSMP) For Adolescent and adult stutterers (2nd ed). Cheney, WA: Eastern Washington University. Cooper, E.B. (1997). Relapse or re-emergence: Coping with chronic stuttering. Proceedings of the Second World Congress on Fluency Disorders, San Francisco, CA, August 18-22. Craig, A., Hancock, K., Chang, E., McCready, C., Shepley, A., McCaul, A., et al. (1996). A controlled clinical trial for stuttering in persons aged 9 to 14 years. Journal of Speech and Hearing Research, 39, 808-826. Curlee, R.F. (1993). Evaluating treatment efficacy for adults: Assessment of stuttering disability. Journal of Fluency Disorders, 18,319-330. Dell, C.W. (2000). Treating the school age stutterer: A guide for clinicians (2 ed.) (Publication No. 14). Memphis, TN: Stuttering Foundation of America. DeNil, L.F., and Kroll, R.M. (1996). Therapy review: Successful Stuttering Management Program (SSMP). Journal of Fluency Disorders, 21,1,61-67. Eichstädt, A., Watt, N., & Girson, J. (1998). Evaluation of the efficacy of a stutter modification program with particular reference to two new measures of secondary behaviors and control of stuttering. Journal of Fluency Disorders, 23, 231-246. Guitar, B. (1998). Stuttering: An integrated approach to its nature and treatment. Baltimore,MD: Williams & Wilkins.

52 Cullinan, Snyder & Reitzes / Journal of Stuttering, Advocacy & Research, 1 (2006) 42 63 Guntupalli, V.K., Kalinowski, J., & Saltuklaroglu, T. (2006). The need for self-report data in the assessment of stuttering therapy efficacy: repetitions and prolongations of speech: The stuttering syndrome. International Journal of Language and Communication Disorders, 41, 1-18. Ham, RE. (1996). Therapy review: Successful Stuttering Management Program (SSMP). Journal of Fluency Disorders, 21, 1,61-67. Ingham, R. J., Kilgo, M., Ingham, J. C., Moglia, R., Belknap, H., & Sanchez, T. (2001). Evaluation of a stuttering treatment based on reduction of short phonation intervals. Journal of Speech, Language, and Hearing Research, 44, 1229-1244. Langevin, M. and Boberg, E. (1993). Results of an intensive stuttering therapy program. Journal of Speech-Language Pathology and Audiology, 17, 3/4, 158-166. Manning, W. H. (1990). Media review: Successful Stuttering Management Program (SSMP) for adolescent and adult stutterers. ASHA, December, 87-88. Manning, W. H. (1999a). Progress under the surface and over time. In N.B. Ratner & E.C. Healey (Eds.), Stuttering research and practice: Bridging the gap (pp. 123-129). Hillsdale, NJ: Erlbaum. Manning, W. H. (1999b, October 1). Creating your own map for change. Paper presented at the 1999 International Stuttering Awareness Day Online Conference. Retrieved March 4, 2006, from http://www.mnsu.edu/dept/comdis/isad2/papers/manning2.html Manning, W.H. (2000). Clinical decision making in fluency disorders. San Diego, CA: Singular Publishing. Manning, W. H. (2003). Finding your own path without professional help. In S. Hood (Ed.), Advice to those who stutter. (2nd edition) (Publication 0009) (pp. 117-123). Memphis, TN: Montgomery, C.O. (1997). The benefits of stuttering: Clearing out some roadblocks to recovery. Proceedings of the Second World Congress on Fluency Disorders, San Francisco, CA, August 18-22. Onslow, M., Costa, L., Andrews, C., Harrison, E., & Packman, A. (1996). Speech outcomes of a prolonged-speech treatment for stuttering. Journal of Speech and Hearing Research, 39, 734-749. Prins, D. (1970). Improvement and regression in stutterers following short-term intensive therapy. Journal of Speech and Hearing Disorders, 35, 123-135. Reitzes, P. (2006). 50 great activities for children who stutter: Lessons, insights and ideas for therapy success. Austin, TX: Pro-Ed. Reitzes, P. & Snyder, G. (in press). Response to intensive stuttering modification therapy: A multidimensional assessment of treatment outcomes, JSLHR, (2005), Volume 48, Issue 3, pp. 509-523. Journal of Speech, Language, and Hearing Research Shapiro, D. A., (1999). Stuttering intervention: A collaborative journey to fluency freedom. Austin, TX: Pro-Ed. Starkweather, C.W. (1987). Fluency and stuttering. Englewood Cliffs, NJ: Prentice Hall. Starkweather, C. W. (1999). The effectiveness of stuttering therapy: An issue for science? In N.B. Ratner & E.C. Healey (Eds.), Stuttering research and practice: Bridging the gap (pp. 231-244). Mahwah, NJ: Lawrence Erlbaum Associates. Starkweather, C.W. and Givens-Ackerman, 1. (1997). Stuttering. Austin, TX: Pro-Ed, Inc. Van Riper, C. and Erickson, RL. (1996). Speech correction: An introduction to speech pathology and audiology, 9th edition. Needham Heights, MA: Allyn & Bacon.

Cullinan, Snyder & Reitzes / Journal of Stuttering, Advocacy & Research, 1 (2006) 42 63 53 Yaruss, J.S. (1998). Describing the consequences of disorders: Stuttering and the International Classification of Impairments, Disabilities, and Handicaps. Journal of Speech, Language, and Hearing Research, 41, 249-257. Yaruss, J.S. (2001). Evaluating treatment outcomes for adults who stutter. Journal of Communication Disorders, 34, 163-182. Yaruss, J.S., & Quesal, R. (1999, October 1). Preliminaries to treatment outcomes research for adults who stutter. Paper presented at the 1999 International Stuttering Awareness Day Online Conference. Retrieved March 4, 2006, from http://www.mnsu.edu/comdis/isad2/papers/yaruss2.html Yaruss, J.S., & Quesal, R.W. (2004). Stuttering and the international classification of functioning, disability, and health (ICF): An update. Journal of Communication Disorder, 37, 35-52.

54 Cullinan, Snyder & Reitzes / Journal of Stuttering, Advocacy & Research, 1 (2006) 42 63 APPENDIX A Successful Stuttering Management Program Survey 1. What year did you attend the SSMP? 2. Are you male or female? 3. What age were you when you attended the SSMP? 15-18 years 19-30 years 30-45 over 45 4. What age are you now? 15-18 years 19-30 years 30-45 over 45 5. The SSMP focuses on two main areas of stuttering treatment: use of handling techniques and changes in attitude toward your stuttering. Which area do you think has affected you most since leaving the SSMP? Handling techniques Changes in attitude toward stuttering Both have affected me equally 6. Which handling technique do you use the most? Prolongations Cancellations Pull-outs I do not use handling techniques 7. I feel that I now have the necessary skills to control my speech. All of the time Most of the time Some of the time Seldom 8. Have you received additional speech therapy since attending the SSMP? If so, please briefly describe: 9. Do you attend a support group specifically for people who stutter? How often?

Cullinan, Snyder & Reitzes / Journal of Stuttering, Advocacy & Research, 1 (2006) 42 63 55 10. How often do you advertise that you are a stutterer? never occasionally (once or twice a month) frequently (once or twice a week) all the time (at least once a day) 11. Transfer and maintenance of your skills is emphasized during the final stages of the SSMP. How strictly did you follow your maintenance plan? I followed it almost exactly I did about one-third of the items on my plan I did about one-half of the items on my plan I did not follow my maintenance plan at all 12. If you did about one-half or less of the items on your maintenance plan, we would like to know why. I did not have the time or make the time I was over-ambitious when writing up the plan for myself Some of my old speaking fears started to come back Other 13. Do you continue to give yourself additional speaking assignments outside of required telephone calls, conversations, etc. of your everyday life? Frequently (about how often? ) Occasionally (about how often? ) Never 14. On a scale of 1 to 5, how would you rate your speech before you attended the SSMP? mild moderate severe 15. How would you rate your speech on graduation day at the SSMP? mild moderate severe 16. How would you rate your speech today? mild moderate severe

56 Cullinan, Snyder & Reitzes / Journal of Stuttering, Advocacy & Research, 1 (2006) 42 63 Please check the statement that most accurately reflects how you feel: 17. When I first left the SSMP, my ability to communicate in my job or at school had: not improved improved improved much completely at all a little some improved improved 18. Now I feel that my ability to communicate in my job or at school has: not improved improved improved much completely at all a little some improved improved 19. When I first left the SSMP, my acceptance of myself as a stutterer had: not improved improved improved much completely at all a little some improved improved 20. Now I feel that my acceptance of myself as a stutterer has: not improved improved improved much completely at all a little some improved improved 21. When I first left the SSMP, my fears of certain words or sounds had: not improved improved improved much completely at all a little some improved improved

Cullinan, Snyder & Reitzes / Journal of Stuttering, Advocacy & Research, 1 (2006) 42 63 57 22. Now my fears of certain sounds and words have: not improved improved improved much completely at all a little some improved improved 23. When I first left the SSMP, my fears of certain speaking situations had: not improved improved improved much completely at all a little some improved improved 24. Now my fears of certain speaking situations have: not improved improved improved much completely at all a little some improved improved 25. Since attending the SSMP, my confidence in my ability to speak has: not improved improved improved much completely at all a little some improved improved 26. Since attending the SSMP, my general confidence has: not improved improved improved much completely at all a little some improved improved 27. If you feel that the improvements in your speech have regressed, how long did it take before you noticed you were no longer communicating as effectively as you were when you first left the SSMP? 1 to 2 months 3 to 4 months a 4-6 months 1 year Other (please specify):

58 Cullinan, Snyder & Reitzes / Journal of Stuttering, Advocacy & Research, 1 (2006) 42 63 28. Did you attend the refresher weekend offered 6 months after the SSMP? Yes No 29. Would you attend a week-ong SSMP refresher if one were available? Yes No 30. We would like your input on what improvements you think could be made to the SSMP. Please use the space below to give us your feedback. Appendix B Suggestions for Improvements to the SSMP At the request of the supervisors of the SSMP, respondents to the survey were given the opportunity to offer suggestions for improvement (question 30). Many respondents noted that additional refresher sessions would be beneficial and two respondents thought that separate sessions for adolescents and adults would be a good idea. The following are excerpts from other responses: "The program was very beneficial with showing me other people are, 8 times out of 10, very accepting of stuttering. Maybe not educated about it, but very accepting." "No improvements. I have experienced several other stuttering therapy programs and I honestly feel that the SSMP provides the best therapy program in the country." "Organize refresher groups in several geographical locations across the country. Emphasize voluntary stuttering more throughout the program. Have more than one refresher at six months." "Add a session and several rap sessions with a trained clinical psychologist to deal with some of the emotional issues surfacing during the intense program." "More assignments conducted alone (without the support of other stutterers and clinicians). More time spent with clinicians especially when learning handling techniques. Have two social workers/counselors on staff to deal with the other part of stuttering - the years of emotional turmoil. Have SLP contacts available (listings in your area) for when client returns home." "The SSMP was definitely the most complete therapy program I have attended. I still stutter obviously, and some of the fear has returned, but presently I am able to move forward while stuttering much easier... I have discovered that it helps me to "let go" of techniques sometimes and just stutter openly as we did during the first part of the SSMP. I think I have put too much pressure on myself to be on top of my speech all the time, and it does help me to enter situations without techniques and discover that stuttering, even more severe stuttering, won't kill me."

Cullinan, Snyder & Reitzes / Journal of Stuttering, Advocacy & Research, 1 (2006) 42 63 59 APPENDIX C Figure 1. Ages of Survey Respondents 16 14 15 Number of Respondents 12 10 8 6 4 11 7 2 0 1 < 14 15-18 19-30 2 31-45 > 45 Age Groups Figure 2 60 Of the two main focus areas of the SSMP, which has affected you the most 50 53 Percent of Respondents 40 30 20 39 10 8 0 Handling Techniques Changes in Attitude Both

60 Cullinan, Snyder & Reitzes / Journal of Stuttering, Advocacy & Research, 1 (2006) 42 63 Figure 3 50 Frequency of respondents attending stuttering support groups 47 Percentage of Respondents 40 30 20 10 33 14 8 0 Bimonthly Monthly < Monthly Not at all Figure 4. 40 How often respondents continue to advertise that they stutter Percentage of Respondents 30 20 22 31 33 14 10 Alw ays Frequently Occasionally Never

Cullinan, Snyder & Reitzes / Journal of Stuttering, Advocacy & Research, 1 (2006) 42 63 61 Figure 5. How strictly respondents followed maitenance plan 40 Percentage of Respondents 30 20 36 28 19 17 10 Entire Plan One-Third of Plan One-Half of Plan None of Plan Figure 6 Retrospective Self-Ratings of Speech 5.0 Severity (1 = mild, 5 = severe) 4.5 4.0 3.5 3.0 2.5 2.0 1.5 Before SSMP Graduation Day 1.0 1994 1995 1996 1997 1998 1999 Present Day Year Attended SSMP

62 Cullinan, Snyder & Reitzes / Journal of Stuttering, Advocacy & Research, 1 (2006) 42 63 Figure 7. (1 = No Improvement; 5 = Completely Improved) Retrospective comparison of ability to communicate at job or school 5.0 4.0 3.0 2.0 1.0 1994 1995 1996 1997 1998 1999 SSMP Graduation Present Day Year Attended SSMP Figure 8. Retropsective comparison of self acceptance as a stutterer (1 = No Improvement, 5 = Complete Improvement) 5.0 4.0 3.0 2.0 1.0 0.0 1994 1995 1996 1997 1998 1999 SSMP Graduation Present Day Year Attended SSMP

Cullinan, Snyder & Reitzes / Journal of Stuttering, Advocacy & Research, 1 (2006) 42 63 63 Figure 9 (1 = No Improvement, 5 = Complete Improvement) 5.0 4.0 3.0 2.0 1.0 0.0 M ean retrospective responses comparing SSM P Graduation vs. Present Day 3.8 3.6 3.6 3.4 94-96 Graduation 97-99 Graduation 94-96 Present Day 97-99 Present Day 70 Figure 10. Retrospective self-ratings in speaking confidence since SSMP 60 64 Percent Improvement 50 40 30 20 10 19 17 0 0 0 Complete Improvement Some Improvement No Improvement Much Improvement Little Improvement