Articles

Learning communities of specialists in stuttering therapy in Holland - Issue 14, Winter 2000
by Eelco de Geus, Stuttering Centre, Zwolle, Holland
In 1994 a group of specialists in stuttering therapy in Holland started a unique form of co-operation. These therapists, all with their own private practices and institutes, started a learning community in order to improve the quality of their work.
  'The Association of Stuttering Centres in Holland' has, six years later, emerged as a successful group which has implemented several innovative developments. This article shares the process of developing the association with the intention of inspiring specialists in other parts of the world to improve co-operation and networking.
  Traditionally stutterers in Holland were referred to generalist therapists who were not very successful in their treatment. However, in the early 60¹s and 70¹s two major influences led to increased specialisation in stuttering therapy. Firstly, Antonia and Theo Schoenaker (both speech therapists) started a residential intensive group therapy for stutterers which was oriented towards awareness of body tensions and breathing patterns. Under the supervision of Prof. P. H. Damste many clients were treated and many therapists were trained. This would influence developments in Holland strongly for over thirty years. The second major influence was Frank Stournaras, who developed a cognitive approach at Dijkzigt Hospital in Rotterdam.
  In the 80¹s a group of speech therapists who were mainly working with stutterers formed an association and created criteria for specialisation which included a four year training programme. A group of practising 'specialist' therapists resulted. Most of these therapists worked in private practices and faced the same problem, ie health care insurance didn¹t accept the necessary special conditions for stuttering therapy.
  It was hard to get everybody together to generate enough power to bring about change. We wanted to be able to meet the challenges of the rapidly changing world; to create new forms of health care and to optimise the efficiency and quality of our service without losing the core of the therapeutic relationship. We wanted to be inspired and supported in our work but lacked a nourishing environment. The time was ripe for change.
  In 1994 Ad Bertens, a highly specialised therapist and teacher, contacted a small group of therapists who specialised in stuttering therapy. His vision was to create a strong network of stuttering centres in Holland, with connected but still independent workers who would support each other to improve the quality of stuttering therapy.
  We started with 12 people (who hardly knew each other) from all over Holland. Criteria were formulated for stuttering centres which included having at least two fully specialised therapists in each location. In 1995 five stuttering centres opened their doors.
  The mission of the group was formulated as follows:
  'We strive for the highest quality of work with inspiration and motivation.
  We study the needs of each stuttering individual.
  We consolidate our power and knowledge on our way to optimum care.'
  The mission was a first step towards finding a language and definite criteria that the group could agree on. The second step involved formulating the vision of where we wanted to be in five years. In addition, we needed a shared view on stuttering. A consensus was necessary in order for us to be able to communicate well, exchange data and define quality. Ad Bertens formulated a view which reflected recent research findings. This gave a clear guideline for designing therapy plans and implicated a stutter more fluently approach. When mission, vision and view of stuttering had been formulated and agreed upon by the group, we were almost ready to define our goals and start accomplishing them.
  Ad Bertens, the initiator, believed that co-operation should be based on equality, respect and shared leadership. To attain this, it was necessary to learn what each person brought to the group and how to use them effectively. It was also necessary to learn strategies for making group decisions and dealing with conflict. The group chose to let co-operation go hand in hand with the personal development of members.
  We went through a lot of struggle. First, it was hard to agree upon the mission, vision, view on stuttering and on co-operation. During this process people left the group and new people stepped in until a group formed which was committed to working together. We learned that it is important not to give up on mission and vision to keep people; but instead to let the group form organically around the mission and vision. The group can discuss details about mission and vision but the core has to be kept.
Secondly, as a group of therapists who were highly oriented towards personal growth, we initially spent a lot of time and energy on the personal well being of each member. There was a tendency to 'therapise' each other. Our meetings (one day every two months) were too coloured by this and we learned to be more task-oriented. Subsequently, personal growth came in the process of reaching our goals - in working through conflict and dealing with individual differences. We hired people to train us in group process. We held team building events and became a 'learning community' by applying the principles of community building (Peck, 1987). A major difficulty in co-operation was (and sometimes still is) the enormous workload such a mission brings. Sometimes a lot of work was done by a few people. Many tasks were unpaid and out of office hours. To find a balance everyone had to be conscious of their own wishes, possibilities and limits. Through all this process we reached a strong basis on which to build.
  The other struggle related to our position towards the outside world. As a new organisation with innovative goals, we met resistance from other speech and stuttering therapy professionals. In our wish to be connected we negotiated with others, seeking   support and acknowledgement. However, ultimately we learned that instead of reacting to what others wanted from us we needed to be 'pro-active'(Covey 1989) and focus on our own vision, mission and goals (while still remaining open to and connected with others).
Our Goals
Through the years the Association has reached a lot of its goals.
Training and coaching
The stuttering centres developed a strong training programme to enhance the quality of therapy in Holland. Coaching networks were formed whereby speech therapists were coached (live or by phone) by a specialist in a centre. In some parts of Holland health care insurances now pay for the coaching of speech therapists.
Special care
The centres themselves provide individual and group therapy for clients who need more specialist care. The health care insurances are now increasingly willing to pay for 'special needs', such as more time and the possibility of working with small groups.
Integrated Care Program
The stuttering centres developed an integrated care programme for stuttering children (and their parents), adolescents and adults. In this programme clients enrol in a combination of individual and intensive group therapy. They can enter different modules of intensive therapy as appropriate. Modules probe deeper than the stuttering behaviour itself. One possibility for adult clients is to follow 'life-style training'. This helps clients develop a life-style and level of self awareness to support their improved communication skills. The programme of integrated health care was subsidised by a health care fund.
Developing protocol and supporting research
The stuttering centres have developed guidelines for assessment, diagnosis, treatment and prognosis. Working from the same view on stuttering and using the same language, these 'protocols' are useful in supervision and research.
  At the moment a protocol is being developed to evaluate severity of 'timing disorder'. This predicts prognosis for the individual client and defines the choice of treatment goals. The protocol is being evaluated so that it can be standardised in the near future.
  In co-operation with the Institute for New Stuttering Research (INSO), the stuttering centres are supporting research on stuttering prevention. In a long term study, parents of children who are at risk of stuttering are trained in communication and parenting skills by therapists from the stuttering centres in a standardised way. There will be long term (eight year) follow up to see how these children develop compared to a control group.
  Recently an independent study was published about the quality of the activities of one the stuttering centres in Holland. This study indicated that clients and speech therapists were very satisfied with the work of this stuttering centre.
Developing material
In the last few years the stuttering centres have developed several books and materials for therapists and clients. For example, the Screening List Stuttering (Riley and Riley) has been translated,  Bertens & Weeda (1999) published a book for parents about stuttering and De Geus (1999) produced a book for children which was published by the Stuttering Foundation of America and translated into German, English, Italian, French, Swedish and Chinese. Therapists continue to develop and exchange materials.
New Financial sources
The stuttering centres have found new ways to finance their innovative activities. in addition to compensation from insurance companies, projects are being financed by various funds and a network of people who make donations to the Association. A regular newsletter on new developments keeps donators, clients and colleagues informed and involved.
Increasing political power through quality
A major success is the increasing recognition of the role of the centres in health care for stuttering people in Holland. The centres are often used as an example of how quality networks can function. Different associations of professionals are increasingly emphasising the importance of our way of working. The position of stuttering centres in negotiations with health care providers is becoming stronger and stronger.
Parallel process
The process of stuttering therapy is, as we see it, very much connected to personal growth. People who want to change their stuttering, need to have a mission and to find their way towards that. They discover and strengthen their true identity, learn to accept themselves and become pro-active in reaching their goals. They commit themselves to investing time, money and effort in the process of change. The essence of this transformation is from being a victim to becoming a self-assured person who knows his or her own qualities and limitations, someone who can consciously choose how to feel, think and act (Cornelis 1998). Reducing stuttering without addressing personal development is a superficial and short term solution. In order to guide clients in this process, it has proved important for therapists to experience this process themselves. In the six years we have worked together each of us has come to know our own qualities and limitations. We have become more self-assured and learned to co-operate in setting and achieving our goals. We have learned about commitment just as the client learns to commit to the process of self development. We have learned to overcome our resistances and differences just like the client who goes through many phases of resistance and motivational struggle. It is beneficial to have experienced the same process as our clients so we can be their guide.
The future
We believe that network organisations, based on equality and shared leadership, offer a way of co-operating for the future. They offer support, an inspired way of working with others and an efficient means of adapting to the demands of a quickly changing society. They generate creativity and power which individuals may never access on their own. They increase professionalism and quality, bringing satisfaction to  network members and clients.

It seems there is a tendency towards networking and shared leadership in the world today. We would like to encourage other specialists in stuttering to participate in this process and hope that our experiences will contribute towards that goal.

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