Friday, April 6, 2012

Again, First Do No Harm

Recently I was forwarded a comment made by a professor of communication disorders on a professional listserve. She stated that students of speech therapy “MUST be taught that they are not going to make the person who stutters worse by anything they do.” I feel compelled to respond to that by reproducing a section my book, “Voice Unearthed: Hope, Help, and a Wake-Up Call for the Parents of Children Who Stutter.” In Chapter 4, I write about the assumptions we made as parents and one of them was “he loves his therapist and thinks therapy is fun, so it can’t do any harm.” I go on to say…
When talking to other parents at conferences, I often heard about how much fun their child had at speech therapy and about how much they loved their therapist. Eli was, for the most part, no exception. In retrospect, it was easy for us to get distracted by a therapist’s encouraging tone and good intentions and to lose sight of what we were trying to accomplish. Eli didn’t need to go to speech therapy to make friends and have fun. Speech therapy was supposed to help him to speak more easily and none of his therapy helped with this outside the clinic setting.

But therapy certainly didn’t hurt Eli, or did it? First let’s consider the logistics…hours in the car, time in the clinic, and time spent practicing therapy at home - over a five-year period. Add in the financial impact, the cost of gas, wear and tear on the car, and the therapy itself. Well worth it if the outcomes are good. But they were not, and that’s a significant chunk of time and effort out of a child’s life that could have been spent engaged in activities with better outcomes such as playing with friends or hanging out at Grandma's.

Even more importantly, I can’t remember one conversation between myself and a speech therapist that didn’t indicate that Eli was doing great in therapy. And yet our efforts over a five-year period only resulted in:

- Eli becoming more and more silent.
- Eli participating in fewer and fewer activities that involved meeting and talking with
- Eli acquiring secondary problem behaviors including turning his chin to his shoulder, dropping his jaw, and growling to get himself started.
- Eli growing increasingly depressed.
- Eli feeling exhausted and experiencing major sleep issues.

Medical ethics include a fundamental principle of “first do no harm” stemming from Hippocratic writing Epidemics. Hippocrates states that “the physician must be able to tell the antecedents, know the present, and foretell the future - must mediate these things, and have two special objects in view with regard to disease, namely, to do good or to do no harm.”
Speech therapists, parents, grandparents, friends, neighbors – all can contribute to a child’s increased anxiety and tension around communication. There is hope in this statement – because if we can create an environment that contributes to the exacerbation of stuttering, we can create an environment that minimizes the progression and even contributes to the regression of anxiety and tension around speaking. First do no harm, keep them talking!

Doreen (Dori) Lenz Holte


  1. I'm absolutely floored that a professional would make a statement like that. A doctor can cause harm if the wrong medicine is given, a teacher can cause harm if the wrong methods are used to teach, a parent can cause harm if the wrong techniques are used with their children. Would anyone deny those statements? I doubt it - and so how could anyone deny that an SLP could in fact do harm to a child? The scariest part is wondering how many SLP's out there actually believe that nothing they do could have a negative effect.

  2. Thank you for your response. It was a scary comment and you are absolutely right -- the scenarios where harm can occur are endless when it comes to children. I do believe that many professionals (in many professions)are acutely aware of the potential for harm and conduct their interactions accordingly. I also believe that the harm done by most is unintentional -- but harm none-the-less. Hopefully they are listening...

  3. I agree, Doreen - unintentional harm reminds me of the saying: "The road to hell is paved with good intentions"...

  4. Thank you for your comment Peter -- speech therapists who insist that equipping children with speech tools is a must in therapy are doing what they have been told is evidence-based best practice. Hopefully my book will help them to understand the unintended consequences! Over 50 speech therapists have connected with me since the book was published -- resonating and agreeing with the message and grateful for the hopefully progress is being made...thanks again..

  5. "Evidence-based best practice" is another concept which makes me uncomfortable, as it implies a strict, pure scientific approach. In science that's a wonderful ideal, but I'm not sure if it should apply to stuttering. Stuttering contains elements which are not easily boxed into purely scientific compartments, eg. the stress component and the psychological component. For example, the relapse problem with adults who stutter: there's a theory that stuttering relapse can be the result of the 'stuttering subconscious' reacting against newfound fluency. The 'stuttering subconscious' is used to stuttering and rejects attempts to get fluent because it prefers the stuttering status quo. I think this is a wonderful theory, but will it be accepted by therapists? No, because it is very difficult if not impossible to get the necessary evidence so as to create an "evidence-based best practice" based on this theory. Speech therapy limits and retards itself by insisting on "evidence-based best practice".

  6. I totally agree -- especially with "speech therapy limits and retards itself by insisting on "evidence-based best practice." Even worse -- it's not the only example. So many people have pointed out parallels in other fields after reading my book. I also find "the stuttering subconscious" an interesting idea. Are you familiar with Bob Bodenhamer and neurolinguistic programming?

  7. I unfortunately only have a very sketchy idea of Dr Bodenhamer's NLP school of thought. The "stuttering subconscious" was, as far as I know, first propounded by another maverick expert, Dr Martin F. Schwartz, of the National Center for Stuttering (in New York) and formerly a research professor before he retired. I can strongly recommend his last book, Stutter No More, which can be read for free at his website at Dr Schwartz is probably the most controversial of all the stuttering experts. He is now writing another book. His theory is that stuttering is struggle behavior resulting from stress-sensitive vocal cords that tend to "lock" when in stress. He first suggested this idea in the 70s in his book "Stuttering Solved". I believe that he is correct and that he has indeed identified the cause of stuttering. The whole story of how he has been treated by the speech therapy establishment, and the extreme negative reaction to his ideas, must still be told. His treatment, however, is not a miracle cure and requires lots of work. I attended one of his courses in the 80s, and it changed my life, though it was hard work.