This episode is a follow up to episode 68 on assessment cluttering. It’s about treatment, using the M.O.R.E. approach. More than a to do list, M.O.R.E. is a framework to help clients first make the cognitive changes that will lead to behavioral changes.

 M.O.R.E. stands for motivation, ownership, recognition and earned fluency. If you’ve been wondering how to help a client who has plateaued in cluttering therapy, today’s episode is for you! Wondering what earned fluency is? Vivian Siskin shared this brilliant insight in a fluency course—“You don’t learn anything from unearned fluency, you do from earned fluency.” Episode 69 will guide clinicians to helping clients get to earned fluency.

 And because assessment and treatment of cluttering can get—well— cluttered,  there is a cheat sheet for the M.O.R.E. approach in the free resource library.

— Useful Links —

Science Box 

Rubrics to the Rescue 

Stop Playing Whack-A-Mole with Stuttering Therapy 

Rubistar 

James Veitch

Music: Simple Gifts performed by Ted Yoder, used with permission

Transcript

Denise: Welcome to the Speech Umbrella, the show that explores simple but powerful therapy techniques for optimal outcomes. I’m Denise Stratton, a pediatric speech language pathologist of 30 plus years. I’m closer to the end of my career than the beginning, and along the way, I’ve worked long and hard to become a better therapist.

Join me as we explore the many topics that fall under our umbrellas as SLPs, I want to make your journey smoother. I found the best therapy comes from employing simple techniques with a generous helping of mindfulness. Hello, Welcome to episode 69 of the Speech Umbrella podcast. I’m your host, Denise Stratton, and today I’m going to continue talking about cluttering, which I started in the last episode.

I’m not a fluency expert, I just know what works. I think we tend to take fluency disorders and put them into a category that’s for someone with more expertise than me. But the truth is even the experts have to do this hard work of slowly uncovering all the factors contributing to disfluency. It’s not so much a cut and dried ‘here’s a fluency workbook for you’, it’s more of an if/then kind of process, a lot of decisions about what to address, and here’s the news for you, it’s not a linear process. Oh, it would be so much easier. It would be such a walk in the park if it were a linear process. Treating fluency disorders, and cluttering is a fluency disorder, it’s not at all linear and we have a tendency to move too fast in the initial stages, and that just causes problems for us further down the road.

Our, our clients plateau when they don’t move forward. The name of this podcast is MORE Success in Cluttering Therapy. Part Two and MORE is an acronym for my approach. It stands for Motivation, Ownership, Recognition, and Earned Fluency. Something to keep in mind throughout this podcast is the activities I talk about might be the same throughout these stages you’re working through, but it’s the stage where the client is at that changes.

You can use the same activities, but the client is changing. And also there’s some back and forth play between these stages. So a client might have a moment of earned fluency before a moment of ownership. Like I said, it’s not linear and their motivation may increase as they experience success. So you’ve got to kind of keep in mind this is like a circle, and they will just get better and better and better at all these processes, and it will just kind of all come together and you’ll realize, hey, they’ve got it.

So cluttering can be quite complex and the assessment itself is really eye-opening To refresh your memory if you heard the last episode, or bring you up to speed if you didn’t. In part one, I covered assessment and how it’s an ongoing process and maybe issues you weren’t aware of at the start bubble up and you have to figure out what to do with them as they appear during the therapy process.

Which brings us to today, treating cluttering. You know, assessment’s a kind of a secure place. We take our language samples and we analyze them six ways to Sunday. Articulation errors, the disfluencies, which by the way, they all have their own categories. And we also look at the language organization, we might look at phonological awareness if that’s indicated, and explore as their related learning disability.

And we get all this information and we have the tools to do that, and we get a picture of what’s going on. But then what do we really do with it? How in the world do you teach someone not to clutter? Because you know, if telling them to slow down and speak more clearly would work, they wouldn’t need us. I mean, anyone could tell ’em that. While treating related issues is certainly part of the answer, it doesn’t necessarily solve the cluttering, often it just makes it possible to effectively treat the cluttering. So here’s what I hope to deliver today. A solid approach you can rely on to help you with this gordian knot of cluttering. I need to put a disclaimer in here, if your client also has a learning disability, it’s going to be a longer road and your client’s outcome may be different than a textbook cure, but you can still see improvement, you can definitely see improvement.

So are you ready to dive into MORE success with cluttering therapy? Let’s go. M stands for motivation, and I have a little story to share with you about a client named Brett. I actually have a lot of stories about Brett in this podcast. He was just delightful. During one of our early sessions when we were talking about his speech, Brett expressed his opinion that other people should just listen better. He lacked ownership in communication, and this is different from stuttering, so people who stutter are often anxious about how their speech affects others. Brett had no anxiety about how his speech affected others and he didn’t feel the onus was on him to improve communication because he saw no problem with his speech. He had no motivation to change. Fortunately, I was able to do two things. I showed him cluttering was a real thing and he was doing it, and I helped him uncover his why.

The way I showed him that cluttering was real is I videoed him demonstrating a science experiment, which required him to talk it through almost like you see someone on YouTube. Here, this is how we’re gonna do a science experiment. It was a pretty challenging task, and it was meant to catch cluttering on video. Then I had an analysis sheet for him when we watched the video together and made notes of places where his speech was unclear. I really tried to hold back my input and give him the chance to recognize his own cluttering, and only then would I come in and point something out.

While he was watching that video, that’s when he said, my words are being eaten, and he was talking about how syllables were collapsing. Notice the passive voice there. He didn’t say, I’m eating my words, or I’m talking too fast, and syllables are dropping out. That is an interesting insight into ownership at that point.

So some of the things we noted were speaking too fast, syllable collapse, mid sentence revisions, things like that. Whatever it is that your client needs to notice, that’s what’s gonna be on your analysis sheet. We also did an awareness activity with the mirror, and this is how it works. You and your client sit side by side in front of a mirror that’s big enough to reflect both of you.

And while the client talks, you hold up a finger every time you hear a disfluency. The overall point of this, this may sound like recognition, which is what the R stands for. Well, it is a little bit of recognition, but it’s overall broad recognition to bring them to the point of motivation, Hey, I’m really cluttering, and this could be really a problem.

So the outcome of this was first he recognized that he wasn’t speaking clearly all the time. And then he found his why, because he wanted to make YouTube videos about a game he was creating. And he also said he wanted to become a teacher. And later on he found another reason to resolve his cluttering, he really liked to tell jokes and funny stories and I didn’t always understand him. Now it’s a real letdown when you get the punchline and your listener looks puzzled instead of laughing. So we gradually uncovered his motivation in the first few weeks. I have another client who cluttered, who didn’t see any problems with his speech, and I was wondering, oh, should we continue therapy? He’s got no motivation.

Then he got a part in his sixth grade play and he really enjoyed it. He said he liked being in front of all those people, and I recognize that little gleam. That stage struck gleam in his eye because I have actors in my family. Suddenly he had found his motivation. Motivation may take a little while to uncover and it might increase over time, but you have to have it.

So I wouldn’t continue therapy for an extended period with a client who didn’t have it, but you know it’s okay to take a little time to help your client find their why. I remember how I mentioned the Science Experiment video. I do a lot of those, and so just as a side note, I wanted to let you know I have a simple tools video on how to put together your own science experiment box so you’re not raiding the kitchen cupboard to the last minute for the baking soda and the vinegar and the food coloring and all that stuff. It’s so handy. I just have everything in my science box.

And also I talked about sitting in front of a mirror where you’re both reflected and that can be kind of hard if you just don’t have a mirror on your wall. But I found that an inexpensive, full length mirror, you know, the kind you hang on a door works great if you turn it sideways and put it on chair seats and then you sit in front of it.

Let’s move on to oh four ownership. And I wish it were easier to get to ownership, but something so momentous doesn’t come easily. I can tell you the exact moment Brett took full and complete ownership for communicating clearly. It was five months into therapy, and he was telling me a story about something that happened at school when he mixed up the order of his words. He said in front of take it rather than take it in front of the class.

And I wrote exactly what he said on the white board and said, This is what I heard. Seeing his error in print was really, really significant. In fact, he lowered his head for a few minutes, just kind of taking it in, and I did not interrupt that moment. It was really sinking in, the cost of not taking ownership of his speech, and after that moment his progress accelerated.

I think it affected him so deeply because there was nothing abstract about the error of his word order. He could kind of excuse himself for speaking too quickly or making mid-sentence revisions or using run-on sentences, all of what you did, because everybody does a little bit of that anyway and he would give himself outs for that.

But he really couldn’t explain away saying something like in front of take it. I mean, he knew perfectly well how to order his words correctly, and he recognized other people don’t make those kind of mistakes. When clients get in a rush like this, I love to tell ’em this analogy. So I love to hike and I like the challenge of a steep mountain. And when I was younger, I loved to hike fast, and although I knew perfectly well the three points of contact rule, you know, always have two hands in one foot on the mountain or two feet and one hand. I didn’t always follow it, and I felt in control most of the time, but sometimes I’d get a little rush as I just like break that rule and make a little jump or whatever up the mountain.

Really silly. Fortunately for me, I didn’t fall when I was being careless, and now that I’m older, I don’t do that anymore. But the same thing applies with speech and language. Some of our kids get going so fast, they lose control. They’re not too worried about it. Hey, I’m in control most of the time. But really, you’re talking all the time. You’re talking so much. Communication is so important. You will fall if you go so fast that you lose control and there’s gonna be consequences. So just watch for those moments when you can help your client really take full ownership. I couldn’t predict that. I didn’t plan. I was just ready for it when it happened and I seized that moment and Brett really understood, Hey, I need to watch what I’m saying and how I’m saying it and how fast I go.

Okay. Let’s move on to recognition. Here’s where we get down to brass tacks. So here’s where a lot of the activities that have to do with what you’re gonna do in therapy come into play. Now similar to stuttering, clients who clutter don’t recognize in the moment what kind of error they’re making or even exactly when they’re making it.

And I talk more about this in episode 48, Stop Playing Whackamole With Stuttering Therapy. If you don’t know what is happening when, you simply can’t correct it. 90% of what I do when treating cluttering is centered on recognition. Now with stuttering, you’re gonna add in techniques for fluency once clients get to the recognition stage.

But my experience with cluttering is that you often don’t need fluency techniques because recognition is enough for them to get on that path to achieving fluency. They don’t have the same kind of motor struggles with getting stuck on sounds. So recognition and practice with organizing their language are my go-tos.

I work on recognition in kind of two phases. So one is shortly after the fact, so shortly after they’ve been speaking, they listen to recordings of themselves or of me, cuz I model sometimes and they identify cluttering moments. Then redoing the recording and correcting it, the redo is super important. It proves to them that they can be in control.

And when I say we identify cluttering, I mean we identify everything associated with it. Speaking too fast, syllable collapse, run on sentences, lack of conjunctions, which leads to run on sentences. And we may not tackle it all at once, but no stone is left unturned. It sounds like a lot of work. It is a lot of work actually.

But thankfully as they start to get control of even one little part of their problem, it has positive effects on all the other issues. So the sum is greater than the parts. And then I work on in the moment recognition. So at the moment, cluttering is happening or lack of language organization, they recognize it.

You could use the mirror activity I talked about earlier, sitting side by side in front of the mirror and raising a finger every time disfluency happens, first you do it as the clinician, then they do it for themselves, so that’s where they’re recognizing it themselves. Or you could do it for each other and you could make these errors on purpose and they recognize it in you.

You do have to decide ahead of time what you’re going to pinpoint to recognize because these symptoms can be so widespread. So maybe you choose recognizing mid-sentence revisions first, and then let’s add in syllable collapse. And your whole goal, of course, is for them to self correct at the moment a disfluency happens.

But first they have to recognize when it’s happening. I also use rubrics a lot with clients who are working on fluency and when they’re ready for it I add in in the moment recognition. It’s one of the things we score on the rubric that they recognize the disfluency was happening in the moment, and we talk about ways they can indicate that they recognized it was happening.

So right now you might be thinking, okay, Denise, single sentences are easy, but when we move beyond that theme, spin out of control. I might want them to say two or three sentences, but they do not stop there. Or they have one very long sentence that never stops. It’s too much to analyze, too much for them to do a redo on. It’s just too much, they can’t even recognize a disfluency when it’s happening. And how do I get them to just tell me a little bit more than one sentence, but not a whole book? That has been one of my challenges in fluency and in language therapy too. And here are some things that I do. I call this first one, Can I buy a period?

And what I do is I have these penny strips. I have Velcro that I put down on the strip, like I love a wooden paint stick. It’s free, put Velcro on it, and then I have Velcro on some pennies. And so I explain, it’s just like a recipe and we have to have the right amount of speech to analyze. So I will demonstrate and say, I’m going to talk about this and I think I will need two pennies. I think it’s gonna take me two sentences and I demonstrate and I show them how I put down a penny when I end the sentence. That’s my period. This is a way to control run on sentences and also a way for them to use that small chunk of speech that you need that is going to work just for analysis.

Let them plan ahead how many pennies they’re going to use and challenge them to meet that goal. And I tell you, if they’ve had a problem with this, it’s not gonna work right the first time, they’re gonna hold those pennies in their hand and they’re just gonna start talking and you’re looking at them like, are you gonna end the sentence? Are you gonna put that penny down? It takes them getting used to, but they’ve got something physical, they’ve got something visual to remind them I’ve gotta stop this sentence. Another thing I love to do is talk about what interests them. Now I have games like, Would You Rather, and I have card games and such, but I rarely use them anymore for this kind of conversation.

I much prefer to talk about their interests and I feel it forms a better client therapist relationship. So find their passion and they will usually want to talk about it. For Brett, it was his world building that he was doing. He was creating this whole game where, oh, he was creating a role playing game and he had this whole world in his mind, and he loved to talk about it. For another client, it was sports. He played every sport under the sun so we could go on forever. Uh, for another client, it was her job at a specialty cupcake bakery. But in order for this to work, you have to emphasize that we are controlling the amount of language you’re going to use at each conversational turn because that’s the reason you’re here.

You’re here to work on this. And sometimes they’ll say, tell me in two or three sentences about this, and they can do this. They can understand these concepts. These are preteens and teens that I work with. I have never had a really, really young cluttering client. And when you’re using that voice recording app, they can see the wave forming. They can see when it stops for a sentence, when it doesn’t stop for a sentence. They love to watch that, and I think that’s really helpful. And here’s another idea. I love to use story-length jokes. I have a whole book of story-length jokes. These are ideal because you can have a joke that’s just a few sentences and you can have a joke that takes almost a full page to tell.

So you can choose whichever one is right for where they’re at. They appeal to a wide age group. They can take it home and tell it to their parents. They can tell it to their peers, and this is what’s really interesting that much of the time they have control until the punchline and then the disfluency happens, and that’s when they lose control. It’s really important to practice getting successfully through to the punchline. There is something about disfluency where, I don’t know, the brain saves the error for the most important moment. The punchline, the thing that’s most important to say. That’s when things fall apart, and that’s the most important part.

So you’ve got to practice getting past that. I also love to tell personal stories and as they tell personal stories, we practice including context. That means the setting, the people’s names. The things that are really important for someone to understand the story and keeping it concise because they can go on and on and on.

One thing I love to do is show them videos of comedians and how much context they provide. A comedian really sets up the story so that the audience knows exactly where they’re going, and also they slow their language down when they get to really important parts, which is the opposite of what our cluttering clients do.

They speed up when they get to the important part, and then you can’t understand it. And that’s one of the things Brett had difficulty with was including details in his stories. You felt like he’d just been dropped in the middle of his story when he started telling it, and he loved the comedian James Veitch. I think I’m saying that right. Anyway, he’s the one who plays jokes on internet scammers, he’s so funny. So we watched one of his skits together and we paid attention to how much information he gave to set up the story and his rate of speech. And that really made a huge impression on Brett. And because Brett didn’t have a language disorder, he was able to rather quickly learn how to correct these issues that he was having, and give lots of context for his stories and organize his language better. His language issues were due to a lack of attention. He just hadn’t thought about how to put his language together in a more organized way. Last but not least, script reading. Okay. I love using quotes from the Princess Bride movie, and most of my clients are familiar with the Princess Bride, and most of them love it.

If they’re not familiar with it, you can watch these little clips. So when we watch these little clips, we notice where the actors change intonation and try and imitate it. We’ll even highlight it with a highlighter, as in Vincini saying ‘Inconceivable!’ I usually save this kind of work with prosody till the very end. Prosody is like the icing on the cake with disfluency disorders. You have to have this other stuff under control, and then you can work on fine tuning things. And with Brett, it was really interesting that he kept making just one error. Just one error when we were doing this script rating, but because I knew he could do it, um, I knew what his capabilities were. I just said, Do it again. Do it again. I said, I doesn’t matter how slow you go, slow equals control. That’s not always true with stuttering, but it is true with cluttering. In this case, I just want to do it without error. And that persistence on his part really, really paid off because for him it was just a matter of making himself do it, making his brain take control of his mouth and going through these scripts and saying these lines without any errors. That was a real turning point for him.

Finally, we’re to the E in more, which is for Earned Fluency. What does earned fluency even mean? Well, I took a stuttering course from Vivian Siskin and she said you don’t learn anything from unearned fluency, you do from earned fluency. Our clients experience unearned fluency or accidental fluency all the time. That’s when their speech is clear and their rate is controlled, although they have no idea how they’re doing it, they have a lot of that. Everyone who has a disfluency disorder has a lot of unearned fluency where you’re just fluent.

It’s only when they’re able to make changes in the moment, from disfluent to fluent or unorganized language to organized language that they learn how to do this for the rest of their lives because now they’re in control and they’re knowing I can actually change this in the moment. In Brett’s case, it was four months before he had his first moment of earned fluency, and four months after that he exited therapy.

So that just illustrates my point that this is not a linear process. Because you might think, oh, he got to earned fluency now it’s just a short little while before he’s done. But that was just his first moment. And so we still had moments of working on recognition and ownership and things like that. His motivation was pretty strong by that point, but it was another four months before he grasped the whole concept.

And I also wanna point out, as I said, he didn’t have an associated language disorder. I think someone with a language disorder and cluttering is going to take longer than that. You’ve got a whole bunch more to work on. But the way to get to earned fluency is by working on the motivation, the ownership, and the recognition parts.

Finally, I would say know your goal. Your goal of fluency is forward moving speech and not perfection. For some clients, nearly complete fluency is realistic and no one’s completely fluent. And I knew that was realistic for Brett which is why I pushed him to that when we were at the very final stages of his therapy.

But anyone can achieve forward moving speech, and that means they’re able to correct themselves, to not repeat themselves or interrupt themselves to keep the conversation going forward, and to have people understand them. It means they use earned fluency when they need it, and they keep moving forward.

That is always your ultimate goal with fluency therapy. And no one needs the pressure of perfection. Well, that is the M O R E of how I do cluttering therapy. I talked about rubrics a lot, and I have some rubrics for fluency, on Rubistar For Teachers, and I’ll link that in the show notes. I have a whole podcast I did about Rubrics to the Rescue is what I called it, about how valuable they are when you’re working on something really complex like cluttering.

And so you can go there and you can see my rubric. Um, you search for me, [email protected]. My rubrics will come up and the cool thing about them is you can save them and you can change them to however you want to and use them. And I also have made a cheat sheet for working on this MORE approach that you can get in my free resource library, cuz I know that’s a lot to keep in your mind at once.

So you go to thespeechumbrella.com/free, and so you can get that M O R E cheat sheet. And I’m also going to put all the things I said about assessment on that cheat sheet also. To wrap this up, remember you need motivation, ownership, recognition, and earned fluency. And when you get the motivation, ownership, and recognition going really well, the earned fluency starts to take care of itself.

Thank you for listening, and please join me again in two weeks for more tips on speech and language therapy.

Thanks for listening to The Speech Umbrella. We invite you to sign up for the free resource library at thespeechumbrella.com. You’ll get access to some of Denise’s best tracking tools, mindfulness activities, and other great resources to take your therapy to the next level.

All this is for free thespeechumbrella.com. If you’ve enjoyed this podcast, subscribe and please leave us a review on Apple Podcasts and other podcast directories.