Writing Goals for Stuttering

Marisha (00:01.73)

Hello there and welcome to the SLP Now podcast. I'm really excited to have Nina Reeves on the podcast today to continue our series on goals. And today we are talking about stuttering. and I'm sure you've already heard of Nina Reeves and know all about her, but just in case she is, a board certified specialist in stuttering, cluttering and fluency differences.

And she's also an ASHO ASHA fellow and the co-owner of Stuttering Therapy Resources. And she has over 30 years of experience and just has so many phenomenal resources. This intro does her like zero justice, but yeah, you're going to fall in love with all of her resources and knowledge and expertise as we go through. So hello, Nina.

Nina Reeves (00:59.515)

Hello there, how are you? I'm just glad to see you again and talk to you again. I really love when we have our chats.

Marisha (01:01.676)

Great, how about you?

Marisha (01:08.522)

I know they're the best. So let's dive into all of the content we have planned today. Would you mind first just sharing a little bit about your story? Like how did you end up becoming a board certified specialist in this area and what has your journey looked like?

Nina Reeves (01:28.891)

Well, that's a, I love when people ask me about the history because my history can be sort of anyone's story in many ways. I was a brand new SLP coming out of the university and saying, you know, I'm going to take on the world. I was a CF in the middle of nowhere, Illinois in a cornfield. And I was an itinerant and I was bouncing between school districts.

not even school campuses, but school districts. They were all separate rural school districts and I was their itinerant SLP. And I met my first kiddo who stuttered on my own. And I realized probably, I don't know, less than six months into my career that I really didn't know what I was doing. Like I had so much training.

in stuttering because I was trained by a Van Riperen trained guy who stutters. That was our professor. And I should have known better, but I got to the district and the lady that was there before me had been there 30 years. And she was writing fluency goals and doing all these things about fluency enhancing. And even though I knew better, I let my brain, you know, sort of

go away. And I just knew about six months in, I wasn't doing this kiddo any good. So I just launched myself into self study, you know, and because I knew he needed me almost more than any other child on my caseload, that he was struggling just with communication. And trying to be fluent was actually causing more trouble than it was worth.

And so I embarked and it sucked me in. The big hole that sucked me in and I never came out.

Marisha (03:30.966)

Yeah. So now 30 years later, here we are. I love that. okay. So. But let's dive into, cause we're the title of this episode is stuttering goals. But writing goals is actually like a really tiny part of the puzzle. Right. And we want to make sure that we're doing a high quality assessment and also.

Nina Reeves (03:33.4)

Here we are. Here we are.

Marisha (03:59.722)

incorporating neurodiversity affirming and evidence based practice. what are some, can we have a quick discussion about some of the things that we want to think about before we dive into the goals?

Nina Reeves (04:13.874)

absolutely. It's so fun when people invite me to talk about goals because what everybody would really love me to do, I found out over the years is provide a goal bank, which Scott, Scott nor I will ever do. We have a pact that there will be no goal bank. And here's why. First of all, or well, you'll hear that through the next few minutes as we talk, but

Marisha (04:27.544)

Yeah, where's our gold?

Nina Reeves (04:41.741)

The first thing we have to know before you ever put pen to paper on what am I going to do with this kiddo is finding out where this kiddo is, where they've been, where they are now and where they want to go. And so that's that multi-dimensional assessment. The problem is, is that history in our profession has created a space, especially in the public schools, where there's got to be some kind of fluency count, right? And a lot of people focus on that.

And that becomes problematic right away. So let me tell you why. Okay? You probably already know why people listening know why, but I'm going to say it out loud to confirm your suspicions.

Counting stutters is, as I say, like chasing a greased pig. You're going to get it sometimes. You're going to miss a ton of them because it's when we count stutters in an assessment, we are counting what we can see. And so many of a child's stutters are beneath the surface. We're never going to see them. OK, it's really supposed to be about how stuck

that child is feeling under the surface, on top of the surface. Yes, we can see some of the things, but then we start creating a problem that we're objectifying the listener's experience of that child stuttering, not their experience of it. And we're missing a ton of information if that's primarily what we're looking for or basing our assessments on. Stuttering is at its core variable.

It's going to change from moment to moment, day to day, time to time, situation to situation. And so trying to decide that fluency counts are anything more than just what they make me do every three years is a waste of my time. So I'll do it right now until we find another way to get there. But it won't be something I will base my therapy plan on.

Nina Reeves (06:57.846)

I do think it's worth looking at because I get rich and salient information while I'm doing that. I'm looking at the observables and I'm saying, that's great, whatever, you know, that I'm not going to base anything on that, but I'm getting rich information. Is the child avoiding? Is the child pushing? Are there any kind of struggle behaviors happening? And all of that I'm getting from case history.

and I'm getting from working with the student themselves. So that's fine.

In that, I want to say, if anybody out there has heard me talk before, they know I'm going to bring up the ICF model, the International Classification of Functioning Disability and Health from the World Health Organization, which by the way, is smack dab in the middle of our scope of practice. It's how we are supposed to be working with every kiddo that we work with, every client, every adult, every patient.

we're supposed to be looking at the ICF model for our referral, our assessment, our therapy planning and our documentation. And if the people listening right now have never really gotten into it, I'm going to tell you, we'll put it in the show notes. I'll put the one that's on the ASHA website and then I'll put the one that my co-author Scott Yaros and his colleagues over the years have done a lot with for

how it relates to stuttering. And it's gonna change your world. Because then you look at it and you go, I'm going to assess, okay, I'm going to assess the child's function, okay, how stuck are they getting? What are the differences in how their speech system is functioning? But then also reactions, environment, and impact. Reactions being the thoughts, feelings, and behaviors that happen.

Nina Reeves (08:59.148)

because I'm a person who stutters in a world that doesn't get it. Okay? It's not even always a reaction to the actual stutter. It's a reaction to being and experiencing the world as a person who stutters. And so that's a huge part of what we're supposed to be looking at in an assessment and then writing goals for. And then the environment, how people perceive.

What's going on? What do they know about stuttering? What do they not know? What are the wrong things they've picked up? What are the facts we need to fill in? And then the impact. How is stuttering impacting this child's communication?

I could go into a ton on IDEA with the school base, but I'm just going to say communication, not academics. Don't let any administrator tell you it has to be clouding the academics. It's clouding the communication that invariably leads to adverse impact in education. So we want to look at that ICF model to set us up for success because I'm going to talk about that when we...

you know, when we go into how to write goals.

Marisha (10:19.35)

Yeah, that's perfect. so, cause you said that you still include, you may still include like the language sample kind of stuttering counts in your assessments, but what, and I know we don't have time to fully dive into this, but what types of components would we be including in like a gold star evaluation that address more of that, that I, the complete ICF model.

Nina Reeves (10:49.4)

Great question. Let me tell you, I may include it. I actually haven't, unless I've been forced to by some kind of institutional system that says you have to. I haven't done a fluency count on a kiddo. I can't even tell you the last time. And I literally have, well, we won't get into it. So here's the deal. To get into the ICF model, sure. You've got to...

take a look at how this child is stuttering. Yeah, it's just your observable behaviors. That's fine. We get some information about that as long as we look at it in context. And then we're gonna talk to the child and ask them questions about how their speech is feeling. Not how it sounds to us, but how their speech is feeling. And...

Scott and I have written extensively on this over the years. Many people address this. There's resources out there to help SLPs learn about how to interview kiddos or use questionnaires. Definitely that the history surrounding the kiddo, which means we're going to talk to the people in the child's environment. We're going to have them fill out some case history forms and some checklists and questionnaires.

because we want to know what they've been observing. Many times a caregiver can tell me a lot about whether the child is maybe changing words or, you know, not talking as much as they used to. These are all very big pieces of diagnostic information for me. So we're going to look at the whole child from the child, from other people. And

we're also going to take a look at how they think and how they feel. Okay, so that's going to be things like the OASIS, the behavioral assessment battery. There's many things out there. Stuttering anticipation scales, things that are there in our world that we can locate and use to make sure we're finding out is the child, does the child have any negative

Nina Reeves (13:11.749)

affect, thoughts, I can't talk, people don't want to listen to me. When you're interviewing a child and you're hearing words like, I messed up, I stuttered, that's diagnostically significant. If a stutter is a mess up, then we have some negative affect, thoughts and feelings. So I want to be looking at all of those things. We get the environmental information and the impact from

taking a look at the whole child and the Oasis gives us so much. The overall assessment of the speaker's experience of stuttering. The speaker's experience of stuttering. So that would round us out and give us such great information that a child may never say to us, but it's from seven and up. If you have a kiddo that's in that age range, you can find out.

if there's something there that you'll be addressing and writing goals on.

Marisha (14:17.708)

Yeah, I love that. And so, and we'll have a recap in the show notes too, to like the specific assessments that you mentioned, but I think a helpful framework is getting like interviewing the student, getting their questionnaires, reading skills, whatever that might look like, talking to other people in the environment, like parents or teachers. And we have different ways that we can do that as well. And then,

I'll see if we can gather some additional resources too, because you've written so much on all of these topics and we don't have time to do them all justice, but there's a lot of rabbit holes that we can go through to learn more about how to structure those interviews and which tools to use. So we will share that in the show notes as well. Okay. Anything you wanted to add along that train of thought?

Nina Reeves (15:00.957)

Yes.

Nina Reeves (15:04.403)

Great.

Nina Reeves (15:10.601)

Yes, in the assessment and all through therapy, I would love to watch us all as a profession consider ourselves detectives. I call it the SLP stutter detective, which means when we get a kiddo, let's just say even, okay, you get an initially value detecting. We already know that. I want us to look at any child that comes in and even ones we've been working with, sometimes step back and go, let me find out.

what this child has learned, has learned that's wrong, has to unlearn, or doesn't remember. Because we rely on reports. Well, that may be what they worked on, does the child, did the child understand it? Do they remember it at all? So I want us to, in those ongoing assessments, is to find out where are the gaps? What is this child not learned? Or what is

what is therapy not addressed for this kiddo or their family in the past? Because then I can go fill those gaps before I try to move on to anything else.

Marisha (16:22.2)

Perfect. then, so let's say we had like a gold star assessment and we incorporated all of that information. How do we use that to then transition? how do we approach writing goals and what's a effective way to navigate that?

Nina Reeves (16:40.585)

Well, you know, it's so fraught with nuances, but I'm going to try to boil it down.

Nina Reeves (16:52.135)

Some of the most important considerations that I keep in the back of my mind while I'm considering, as Scott and I call it, goal choice, not just the writing, but the choosing of what we're going to try to tackle, first, second, third, and then sometimes you have to sort of regroup and try different things. besides the fact that the ICF model

is going to now lead you into goal writing. You you're going to say, okay, where are our areas of strengths and challenges in the areas of function, reaction, environment, impact? And how am I going to address them? And which ones will be the most, I call it bang for your buck, you know, like what's going to get us the most movement right away? And the problem is, is that people

Imagine they go referral assessment tools, speech tools, strategies, skills. And I want to tell you neurodiversity affirming therapy practices do not do that. We are stepping back a whole lot from that idea that that's all SLPs do is teach kids strategies.

And I'll address that in a moment. But when I think about it, I want to look at, is this child, is this student, is this client involved in setting out what Ali Burke has from England, from the Palin Center calls best hopes? I have now decided that I'm not going to talk too much about goals anymore. I'm going to talk about best hopes because you know, goals like either get it or you don't. It's like a...

too contrasting. I love the idea of what are your best hopes for your communication this year? And I want my students when they're ready to be able to get into that with me. And so is that team, is that student involved in sort of being involved in their own therapy or we just writing goals for them? I think that's an important aspect. The second thing is I always ask myself, why am I doing what I'm doing? Okay.

Nina Reeves (19:19.643)

I'm writing this goal. Is there a principle behind this? Is there a reason? Is there evidence base?

I want to make certain I understand why I'm writing that down before I write it down. And then number three would be how do we get there? Because it doesn't matter what words you write. That's why Scott and I are like no gold banks, because you can write as many things from our gold bank as you want, but you may not have any idea why it's there and what to do with it. So the

what prerequisites are needed before we get into these kinds of activities that align with this goal. So there's a lot of thinking about this and not just about what can I put on the page. Unpopular opinion, but I have big shoulders, I'll take it. And then thinking, there's a couple more things. I would absolutely wanna know what is the intent

of the goal. Okay, so even if I know why I'm doing what I'm doing and how I'm going to get there, what is the overall intent of this goal that's going to take me into therapy practice? Okay, and if I move into practicing therapy or doing therapy practice with this student, does the student know why I'm doing what I'm doing, why we're working on what we're working on, and what the intent is? And here's where we get

into neurodiversity affirming, know, solidly. Because we have to be thinking, are we stepping back out of that medical pathology? Okay, where the intent of stuttering therapy was to make kids fluent. Stop their stuttering, make them stutter less, make their stutter. I've even heard SLPs say, we're just trying to make their stutter less noticeable.

Nina Reeves (21:23.13)

which is total masking. If we stop, step back and say stuttering is natural for people who stutter. my gosh, wait, what? You know, it's verbal diversity as we say, okay? And you were with me when we talked about verbal diversity the first time and blew up the summit on that one. It was like,

people went crazy because all of a sudden everybody had that mindset shift or the beginning of it or the validation of it that these kiddos have a different way of talking sometimes. Okay, they're all different from each other. But why is it okay to be everything in the world but it's not okay to stutter? What is that? It's, well, it's ableism.

You know, it's honoring quote unquote fluency above anything else. And we really have to think about that. It doesn't make us bad people, but we have to be thinking about what the unintended message is. If these kiddos only hear, yay, you did that fluently. You didn't stutter once. Then the opposite of that is make sure that you don't stutter because stuttering is bad. So what's the intent?

If I'm doing any kind of anything, is that to help this child communicate easier, more joyfully, more spontaneously, to become authentic instead of worrying about how they're talking. Okay? If I'm presenting anything that ends up being, so you don't stutter as much or even the unintended message of that.

then I'm off away from a goal that would be neurodiversity aligning.

Nina Reeves (23:29.143)

And number five is the most important thing is the goals that I'm writing, are they meaningful? Do they help this student have a feeling of successful communication that is not defined by how many stutters they had? It's successful communication where they just, they say what they want to say, when they want to say it, to whom they want to say it. Stutter and all.

Because if we take off this idea of fluency and look at what we are, we're communication specialists. I may not be passionate about this. We're communication specialists. So why aren't we focusing on whether this child is accessing the curriculum, saying what they want to say, going out for the extracurriculars that they want, making friends, connecting with other people?

rather than focusing on are they using their tools. That's a fixing message. And kids who stutter don't need fixing. need support and allies and they need to know, number one, it's not only okay to stutter, but it's okay to stutter. Not it's okay to stutter, but go back and make that one smooth. What? Wait.

That's totally opposite.

Yes, we are going to help them. If they're struggling with stuttering and if they're pushing their words out, yes, we're going to find ways to help them ease up that struggle. But it's not going to be focused on a bunch of strategies. They're still there in the background, but the fluency stuff that we have been focusing on for decades is taking a backseat. And sometimes it's not even there.

Nina Reeves (25:28.397)

I know that sounds unpopular opinion again, but it's really true that when a child starts to understand that they're okay exactly how they are, they stop fighting with their stutter, which makes struggle less, it happens less, and nervousness and worry and all the reactions.

It's a big switch for us, but it is the way in which we see stuttering in a social relational model rather than a medical model.

Marisha (26:09.11)

Yeah. I love that. I love how you explained that too. have like, I bookmarked a bunch of stuff as we were recording. was like, I need to write that down in that, that one in that. so many good things. yeah. Thank you so much for breaking that down. And like you said, we've been doing things. Well, a lot of us have been doing things very differently for like, you said decades. And so.

what resources would you recommend for SLPs who are like, okay, this explanation makes sense to me and I'd like to try to implement this and learn those strategies or not strategies, like understand the approach and how to navigate that in my therapy sessions or in our therapy sessions. How would you recommend that they start that journey? Like what resources would be helpful?

Nina Reeves (26:52.441)

Yes, I get you.

Nina Reeves (27:08.865)

Okay, so many. The good news is that there's so many, right? Don't overwhelm yourself. Number one, take small steps. The first thing is what you just said. I recognize that I have to make some shifts. Everybody's in a different place. Some people listening to this are going, yay, I've been doing that for years, right? Other people are going, uh-oh, I just came out of...

university and my professor said, we are going to use timed syllable speech. And they're looking at what I'm saying and going, this is so opposite. Now we won't panic. We can be neurodiversity affirming stuttering therapists by looking at the idea that

strategies and skills are less as less part of the puzzle as we thought and we're going to have to get some centering ideas about what's in our scope of practice but may not have been trained for us counseling in communication disorders and differences now the minute i say that we're counseling everybody's like they get all scared

Okay, if you haven't had a lot of this, that's okay. I never had a counseling course. Everything that I've learned over the years has been from other people, self-taught, diving into the literature, finding the resources that I'm going to put in the show notes. There's this idea that you don't have to be a counselor to have some skills of how to, it's really relational.

Counseling is relational, right? It's listening and discovering and being curious so that people that you're working with actually find these things on their own over time. And so there's a lot of things out there for, especially in the world of stuttering, how we bring those skills of acceptance and commitment therapy, cognitive and behavioral therapy. I love...

Nina Reeves (29:36.19)

avoidance reduction therapy. Some of the things coming out as a solution focused therapy from the Michael Palin Center in England. There are many things that we'll put in the notes to help people know that you can find this information out there and bring it bit by bit into your mindset shift that then shifts your practices.

First thing always, shift the mindset. If you're sitting here and going, this makes sense to me, I just don't know how to do it, you're gonna find ways to do it because now it makes sense to you. And when I say stuttering is verbal diversity, so many of my colleagues and other, and people who stutter just have this big sigh of relief. Like, I always sort of figured that.

I never felt like a fluency strategy was the way I was supposed to be going or trying to make them be fluent because I could never make them all fluent anyway. So I was just doing things over and over and I was frustrated and they were frustrated and the caregivers and the teachers, everyone was frustrated because I wasn't making them fluent. And you're validating. I am, me. And now you and I together are validating.

That was never really the point. It's what society thinks is the point. Because listeners have to take a chill pill. They have to get into the idea that people who stutter do not need to change themselves so that we feel more comfortable. Like, let's get desensitized to hearing different ways of people talking. And that's what stuttering is. It's like accents, it's like different languages, it's like whatever.

People speak differently. Stuttering is one of those things.

Nina Reeves (31:34.486)

Let's get on board.

Nina Reeves (31:39.755)

So that's part of the resources, is the counseling resources. There's a lot of CEs out there, people are doing a lot of articles. I'll put a couple of articles. One whole entire forum from language, speech and hearing services in the schools, January, 2023 issue was ableism and school therapy for stuttering and autism.

You want to talk? Well, that's where we got the neurodiversity movement was the autistic population said, wait, why do we have to look and sound and be like you when that's not how our neurology works? Same with stuttering.

Marisha (32:29.334)

Yeah. Okay. Amazing. and yeah, so there's a lot more to dive into. I feel like that's the trend with all of these episodes. It's like, it's just the beginning, just the tip. but hopefully this, I hope that people listening, are like, whether you're already implementing like this and it helps you, it's a feel good episode. or if you're kind of in the process of like,

Nina Reeves (32:30.41)

Yeah.

Marisha (32:58.05)

figuring this out and exploring that mindset. I hope that this was a great overview for you too. And like we said, we'll have lots and lots of resources in the show notes if you're interested in learning more. But did you have any final thoughts before we close out, Nina?

Nina Reeves (33:18.112)

I think I have one that I can't believe I didn't say at the beginning is that if you want to understand the experience of people who stutter, listen to people who stutter. I'm not the expert in this. I got the speechy stuff background and the experience background because I have thrown myself into the world of stuttering and the support and self-help communities.

I have both of those parts of me where I have realized just because I know it from a book doesn't mean that's what this person needs. So listen to people who stutter. Now everybody's going to have a different experience. So it's not like this person who stutter says I should do this. Wait, stop. Okay, that's great. Bring it in and put it through the idea of evidence base and then try to find ways

to see if that works for this particular child. It's really more about experiential learning than book learning. It's about relating to people and listening to their stories, their experiences. Because once you hear people who stutter, who have been around the block for a while, you will say, I will not try to make people fluent anymore.

that can do more harm in the end. And I have been listening to society say that's what they want from me, even if it didn't resonate with me in the time. So I'm going to get with the facts that I can't cure stuttering, but I'm also going to say that doesn't mean I don't.

that people who stutter are not eligible for therapy and need support and understanding and guidance as a team, as a relational team, you know, navigating my favorite new word. It's not really new. I've been saying it a lot, but I'm really bringing it up a lot. You're helping.

Nina Reeves (35:34.033)

and being an ally and a supporter for people who stutter to learn to navigate stuttering in a world, in societies that don't understand it. And they're going to show up as themselves and learn how to navigate this. Whether somebody accepts it or doesn't, they're going to learn to accept it in themselves. And that's our thought. It's our role.

Marisha (36:06.582)

Yeah. And I feel like I've been pausing after everything you said, because I just want to let that sink in. But yeah, no, this is great. Thank you so much for being so generous with your time and expertise today. And then, yeah, the show notes will be chock full of resources to continue exploring. And man, I wish we had.

Nina Reeves (36:13.714)

Hahaha

Marisha (36:34.188)

way more time to dive in because there's so many more questions, but I think this will be a good starting point and yeah, thank you again.

Nina Reeves (36:43.584)

I appreciate you giving me the opportunity. It's a very obviously passionate topic. And I hope that the listeners can find nuggets in there that help and then resources in the show notes that keep them on their journey.

Marisha (37:04.332)

Yeah, I agree. Well, thank you so much to all of you who tuned in too, and we'll see you in the next episode.