Stuttering therapy with British-Asian children. II: Speech and language therapists' perceptions of...

European Journal of Disorders of Communication, 29,325-337, 1994 0 College of Speech and Lunguage Therapists, London

325

Stuttering therapy with British-Asian children. 11: Speech and language therapists’ perceptions of their effectiveness*

Louise Wright

Carol Sherrard

Department of Psychology and Speech Pathology, The Manchester Metropolitan University, UK

Department of Psychology, University of Leeds, UK

ABSTRACTS Thb paper tested hypotheses anking from the literature on the treatment of stuttering in British- Asian children and adolescents, using data obtained from a postal questionnaire completed by 87 therapists. The results showed therapists treating lower numbers of Asian clients than expected but perceiving their therapy to be less effective with their Asian clients than with their British ones. The variables affecting therapbts’ perceived success were not those expected. Greater experience with Asian clients did not increase perceived success, nor did Asian therapist and client sharing broadly the same cultural background guarantee success. A satisfactory interpreter service did not lead to a higher perceived success rate, nor did postgraduate training or making special changes to usual working practices. On the contrary, therapbts in the last two categories were less likely to perceive success with their Asian clients. Therapists identified a very wide range of cultural factors needing special consideration in therapy, but consensus centred around parental attitudes to stuttering and to therapy.

Cet article teste certaines hypothbes qui ressortent de ce qui a t t t pub12 sur le btgaiement chez les enfants et adolescents britanniques d’origine asiatique, et se base sur les donntes provenant d’un questionnaire par correspondance rempli par 87 thtrapeutes. Les rtsultats rtvPlent que ces demiers soignent moins de clients asiatiques qu’on pourrait penser, et sentent que leur traitement est m o d efticace pour leurs clients asiatiques que pour les britanniques. Les variables qui conditionnent la perception que les thtrapeutes ont de leur propre succis ne sont pas celles auxquelles on pourrait penser: ni, par exemple davantage d’exptrience de clientdes asiatiques, ni le fait que les thbrapeutes asiatiques partagent dans une grande mesure la culture de leurs clients, ni la prksence d’un service d‘interprttariat satisfaisant, ni un entrainement suppltmentaire apris l’obtention du dipldme, ni encore des modifications sptcifiues des mtthodes de travail habituelles - au contraire, dans les deux derniers cas les thtrapeutes tendaient a percevoir encore moins de succ2s auprss de leurs clients asiatiques. Les thtrapeutes ont identifit? un ensemble tr2s vaste de facteurs culturels qui mtri- tent w e attention sptciale lors de la thtrapie, mab l’accord s’est fait sur les attitudes des parents v b d vis du bkgaiement et de sa thtrapie.

In diesem Aufsatz werden Hypothesen aus der Literatur zur Behandlung des Stottems bei brihch- asiatbchen Kindern und Jugendlichen anhand von Daten aus einer postalbchen Umfrage bei 87 Therapeuten iiberpriifi. Die Ergebnisse zeigten, daJ3 die Therapeuten weniger asiatische Patienten

*This paper is based on the research carried out by the first author for her MPhil thesis at Brad- ford University.

326 WRIGHT AND SHERRARD

als erwartet behandelten aber die Therapie bei den asiatischen Patienten fiir weniger wirksam als bei den britischen Patienten hielten. Die Variablen, die sich auf den von den Therapeuten wahrgenommenen Erfolg auswirkten, waren nicht die erwarteten: Gropere Erfahrung mit asiatischen Patienten erhbhte den wahrgenommenen Erfolg nicht, und die t)bereinstimmung im kul- turellen Hintergrund z wischen asiatischem Therapeuten und Patienten war ebenfalls keine Erfolgsgarantie. Ein zufriedenstellender Dolmetscherdienst fiihrte ebensowenig tur Erhohung der wahrgenommenen Erfolgsrate wie ein Spezialtraining fiir Graduierte oder die besondere Umstel- lung der Arbeitspraktiken. Im Gegenteil, Therapeuten der letzten beiden Kategorien verzeichneten einen weniger h8ufigen Erfolg mit ihren asiatischen Patienten. Die Therapeuten identifizierten eine Reihe unterschiedlicher kultureller Faktoren, die bei der Therapie beriicksichtigt werden miissen, zeigten sich aber in der Frage der Bedeutung der elterlichen Einstellung zum Stottern und zur Ther- apie einig.

Key words: stuttering therapy, Asian, children, ethnic minority, effectiveness.

INTRODUCTION Part I of this paper presented the results of a UK survey on stuttering therapy for British-Asian children and adolescents. In this paper we extract data from the survey to test a number of hypotheses which address the following: the relative size of Asian stuttering caseloads as compared to British; speech and language therapists’ perceptions of their effectiveness with Asian clients; variables affecting therapists’ perceptions of their success; and the impact of cultural factors

Although only one paper has directly addressed the treatment of stuttering in Asian children (Lacey, 1987), the literature from a variety of sources raises pertinent questions. Abudarham (1987) mentions reports of a high incidence of stuttering among Asian children in Britain. Numerous studies were carried out as early as 1915, but mostly in the 1950s and 196Os, on whether stuttering was culturally universal, or whether it could be linked to certain social or cultural practices. Lemert (1970) summarises these studies. They are contradic- tory in their findings and most are not systematic. Nevertheless, Lemert concludes that stuttering appears in every culture, but that ‘It is also reason- ably certain that stuttering varies in its incidence from culture to culture’ (Lemert, 1970, p. 175).

The literature suggests three factors which may lead to increased stuttering within a society. First, there is pressure arising from a society’s attitudes towards education, upward mobility and marriageability (Lemert, 1953; Rohrlich Leavitt, 1974), and consequent child-rearing practices. Bloodstein (1987) concluded that a high prevalence of stuttering reflected a culture that was competitive, intolerant of inadequate performance, and which very strongly emphasised the goals of status and prestige.

Second, socioeconomic pressures (Morgenstern, 1956) may be implicated, particularly those experienced by ethnic minorities and immigrant populations who value upward mobility, but whose efforts are frustrated by social barriers against their race, ethnicity or religion (Rohrlich Leavitt, 1974).

Third, a society’s beliefs about stuttering may affect its handling of the problem. Morgenstern (1953) found that the incidence of stuttering correlated highly with the cultural stigmatisation of certain kinds of non-normal speech such as stuttering. Lemert (1962) also contrasted the (low incidence) Polyne- sians, tolerant attitude to stuttering with that of the (high incidence) Japanese, where stuttering is seen as something to be cured and corrected, impeding

STUTTERING THERAPY WITH BRITISH-ASIAN CHILDREN 327

employability and marriageability. A further factor, relevant to Asian children in Britain, is the possible link

between bilingualism and Stuttering. Travis, Johnson and Shover (1937) inves- tigated stuttering in the monolingual and bilingual white immigrant populations of East Chicago, in the USA. They found more stutterers among bilingual children than monolingual: 2.8% and 1.8% respectively. However, they concluded that bilingualism may not have been the only factor contribut- ing to the higher incidence of stuttering but that ‘It may be due to the eco- nomic insecurity and emotional instability found in many homes as a result of the recent depression’ (p. 189). Abudarham (1987), reviewing the bilingualism literature, finds no conclusive evidence that bilingualism per se causes stuttering. He points out there is no evidence of greater stuttering among ‘non-ethnic’ bilingual children, e.g. Welsh or Gibraltan children, and surmises rather that ‘There may be an argument that immigrant Dual Language children may be more vulnerable to psychogenic and sociocultural factors causing disorders of fluency’ (p. 27). He concludes that “‘bilingualism” is therefore not considered to be a precipitating factor - although one suspects it could contribute to a fluency problem’.

Karniol(l992) reviewed the meagre literature on bilingualism and stuttering which she described as inconclusive but ‘sufficiently intriguing to warrant a closer look’ (p. 256). In a contentious paper which contradicts Aburdarham’s conclusions, she describes a young bilingual child in Israel who developed stuttering aged 2;O years while he was the subject of a linguistic study. Karniol hypothesises that simultaneous bilingualism may increase the likelihood of dysfluency as a result of the extra load of linguistic decision-making involved. This argument is, however, based only on a single case.

Leith (1986) describes the situation in the USA as one in which ‘Unfortu- nately, the profession of speech-language pathology has not dealt with the issue of providing services to persons whose culture is different from that of the clinician’ (p. 30). The situation in the UK is a little further advanced, in that there is a growing body of research carried out by Asian and British speech and language therapists on the treatment of Asian clients with a variety of communication disorders. Although not directly concerned with stuttering, some of these are relevant to stuttering therapy, for example, Miller’s (1984) comments on the usefulness of home visits when working with Asian families. The College of Speech and Language Therapists’ publication (1990) ‘Guide- lines for Good Practice for Speech Therapists Working with Clients from Lin- guistic Minority Communities’ provides professional guidelines on a range of management issues.

Speech and language therapists can also draw on the extensive literature on special cultural needs and the provision of effective health care. Literature in nursing, medicine, psychiatry and social work all explore the special needs of Asian clients within their fields (Banks, 1972; Henley, 1979; Cheetham, James, Loney, Mayor & Prescott, 1981; Ballard, 1983; Spector, 1985; Karseras & Hop- kins, 1987; Bennett & Rutledge, 1989). Throughout this literature, common themes are apparent, such as the importance of understanding and accom- modating the client’s cultural viewpoint. In addition, the literature written for general health-care workers provides a wealth of information on cultural


beliefs and practices and how to accommodate them (Mares, Henley & Baxter, 1985; Larbie, Mares & Baxter, 1986). The literature on working effectively with interpreters is directly relevant to speech and language therapy (Shackman, 1984; Barnett, 1989).

Within the cultural-needs literature, only one paper deals with stuttering (Lacey, 1987). It is not a report of empirical research but a description of the therapist’s work with Bengali children and their families in Tower Hamlets. It does, however, raise a number of specific issues. First, Lacey states that ‘All cases are of course, different, but certain patterns do emerge that are attributable to cultural and religious beliefs’ (p. 21). She goes on to describe her Mus- lim clients’ commonly held beliefs regarding the causes of stuttering and expectations of therapy.

Second, she describes how her family counselling therapy has been less successful with Asian families than with British families, as indicated by the fact that her primary school age therapy courses have consistently comprised over 50% Bengali children when their representation in the general school population is 35%. By the time children attend her adolescent courses the number of Bengali participants is 30-40% as compared to the school population of 35%, which she interprets as indicating a higher success rate with Bengali adolescents than with children. Lacey attributes her increased success rate with Asian adolescents to the fact that they may be linguistically and culturally more thor- oughly integrated with their British peers, and that parental support and counselling are not as vital as with young children. She implies that the cultural differences between the therapist and client, or the client’s family, can be significant in the therapeutic relationship.

She also suggests that her lower success rate with Asian children may be attributable to three additional factors: culturally based child-rearing practices may disrupt a child’s fluency, and put Asian children more at risk of maintain- ing a non-fluency once it has appeared; coping with cultural and linguistic differences may disrupt fluency in young children; finally, the inadequate provision of Bengali-speaking speech therapy assistants reduced the frequency of therapy she was able to offer.

Pursuing the questions arising from Lacey’s (1987) article, the study reported here used the data gathered in the first paper to test the following for- mal hypotheses: 1. The percentage of Asian child and adolescent stutterers seen for speech

therapy was higher than that warranted by the percentage of Asian people in the general population.

2. Therapists judged their treatment to be (a) less successful with their Asian clients than with their British ones and (b) more successful with Asian adolescents than Asian children.

3. The following variables were related to the therapists’ perception of their own success: size of Asian caseload; therapist’s own cultural background; quality of interpreter service used; special training received; special changes made to working practices; objectivity of judgement (i.e. whether the judgement was based on objective caseload analysis or subjective impression).

4. Therapists identify specific cultural factors as requiring special consideration when working with this client group.


METHOD As described in the first paper, a postal questionnaire completed by 87 therapists yielded descriptive data on service delivery to Asian children/adolescents who stuttered in the UK. The content derived from each section of the questionnaire is outlined in the Appendix of the first paper. Data were extracted from these survey results, and from the results of questions 6 and 7 on therapists’ perception of their success and of the relevance of cultural factors. These data were cast in the form of frequencies of therapists responding in different categories. Differences between observed and expected frequencies across categories were tested for significance using x* or Cochrane’s Q. For further details of the methodology see Wright (1992).

RESULTS Relative Size of Asian Caseloads Table 1 shows that the first hypothesis of relatively larger Asian caseloads was not supported. Rather, for both children and adolescents, more therapists found that they were treating a lower percentage of Asian clients than would have been warranted by the percentage of Asians in their local population, although these figures were not statistically significant.

Table 1 : Relative size of Asian caseloads for children and adolescents

Size of Asian stuttering case-load relative Frequency Total to local Asian population

Child Adolescent craseload caseload

~ ~ ~ ~ ~ ~

Asian caseload higher than that warranted 30 21 51 by Asian percentage of general population

Asian caseload lower than or in line with 45 44 89 that warranted by Asian percentage of general population Total 75 65 140

Perception of Treatment Success The first part of the second hypothesis was that therapists perceive their treatment to be less successful with their Asian stuttering clients. We found that 59 therapists (75%) did see their treatment as less successful. This result was significant ( ~ 2 = 19.25; d.f = 1; p < 0.001), and confirms the need for research in this area.

The second part was that therapists perceive greater success with Asian adolescents than with Asian children. It was found, however, that only 24 therapists (34%) judged their therapy with adolescents to be more successful, as compared to 46 (66%) who judged their therapy to be equally or less successful with adolescents - a difference that was significant ( x 2 = 6.93; d.f. = 1; p < 0.01). This hypothesis was therefore not supported, and Lacey’s surmise that adoles-


cents are less likely to be disadvantaged in therapy as a result of cultural differences must also be thrown into doubt.

Variables Related to Perceived Treatment Success The third major hypothesis aimed to identify the factors influencing therapists’ low perception of success with Asian clients. The first potential variable was the size of the therapists’ Asian stuttering caseload: a larger Asian caseload was expected to result in therapists perceiving at least equal success with their Asian clients, because greater contact with Asian clients would lead to greater experience on the part of the therapist. Table 2 shows that this hypothesis was not supported: there was no relationship between size of Asian caseload and perceived success.

The second variable potentially influencing perceived success was the cultural background of the therapist: it was expected that Asian therapists were more likely to perceive at least equal effectiveness with their Asian clients.

Table 2: Perceived success with Asian clients, in relation to size of Asian caseload

Sie of Asian Therapists’ perceived success with Asian clients Total caseload (96)

Equal or higher success than with British clients

Lower success than with British clients

0-30 31-60 61-10

Total

11 4 3

18

28 19 5

52

39 23 8

70 ~

Table 3: Perceived success with Asian clients according to therapists’ cultural background

Therapists’ cultural Therapists’ perceived success with Asian clients Total background

Equal to or higher than Lower than with with British clients British clients

Asian Non- Asian

Total

3 17

20

2 54

56

5 71

76

Although the existence of different cultures within the ‘Asian’ culture must be recognised, it was expected that Asian therapists would experience fewer difficulties in understanding the cultural values of Asian clients, thus increasing their perceived level of success. Unfortunately the small numbers of Asian therapists made statistical significance impossible to test. Nevertheless, it is interesting to note in Table 3 that two of the five Asian therapists indicated lower perceived success with their Asian clients. This suggests that therapist and client sharing broadly the same cultural background does not guarantee a high perception of success.

STUTTERING THERAPY WITH BRITISH-ASIAN CHILDREN 33 1

The third potential variable was the quality of interpreter services. Table 4 shows that very few therapists considered that they had a satisfactory service, the low frequency making the hypothesis untestable statistically. However, the hypothesis can be rejected, because the table illustrates that there is no support for it. The five therapists having a satisfactory service all perceived their success to be lower with Asian clients.

The fourth variable expected to influence perceived success was postgraduate training. This was based on the reasoning that, although few therapists receive adequate undergraduate training in the needs of clients from ethnic minorities, postgraduate training may serve to increase skills and confidence in this area.

Table 5 shows that the hypothesis was not supported. On the contrary, it suggests that more therapists with postgraduate training perceived lower success with Asian clients. Unfortunately, the small size of the training ‘Not received’ categories precluded the testing of these figures for significance.

The fifth variable concerned changes to working practices. It was expected that therapists making changes to their working practices in relation to special cultural needs would have a higher perceived level of success.

Table 4: Perceived success with Asian clients, in relation to quality of intetpreter sewice

Quality of Therapists’ perceived success with Asian clients Total interpreter service


Satisfactory Mixed Unsatisfactory

0 2 4

5 10 30

5 12 34

Total 6 45 51

Table 5: Perceived success with Asian clients, in relation to postgraduate training received ~ ~~~ ~

Postgraduate Therapists’ perceived success with Asian clients Total training


Received Not received Total

14 6 20

51 6 57

65 12 77

Table 6: Perceived success wifh Asian clients, in relation fo changes made to working practice

Special changes Therapists’ perceived success with Asian clients Total made to working practice in relation to Asian clients with British clients British clients

Equal to or higher than Lower than with

Changes made No changes Total

1 17 18

30 28 58

31 45 76


This hypothesis was not supported. On the contrary, Table 6 suggests that those therapists who had made changes were more likely to perceive their therapy as less successful with their Asian clients, although as a result of the small size of the higher succesdwith changes category it was not possible to confirm this statistically.

It had been intended to consider a sixth potential variable: whether therapists had reached their judgement of success by objective or subjective means. Unfortunately some ambiguous wording of the relevant question compromised the reliability of the responses. This variable was therefore not tested. How- ever, from the descriptions of methods used, all therapists appeared to have reached their conclusions by subjective means.

Specific Cultural Factors Relevant to Therapy The final hypothesis was that therapists agree in identifying specific cultural factors as needing special consideration when working with this client group. Table 7 shows the extent of therapists’ agreement on specific cultural factors. That certain factors are selected more frequently than others is shown to be significant (Cochrane’s Q = 223.18; d.€ = 12; p < 0.001).

Table 7: Therapists’ selection of aspects of therapy warranting special consideration as a result of cultural factors

Aspects of therapy requiring special consideration as a result of cultural factors

Number of therapists selecting aspect (n = 87)

Frequency Percentage

Parental expectations of therapy Parental attitudes towards stuttering Attendance at clinic Advising on children’s play Meeting both parents Advising on discipline at home Advising on language stimulation Advising on children’s bedtimes Counselling the extended family Referral of pre-school children Referral of schoolchildren up to 11 years Advising on other child-rearing problems Referral of schoolchildren over 12 years Other (see Table 8)

64 53 49 42 32 29 27 26 20 14 11 11 6 5

74 61 56 48 37 33 31 30 23 16 13 13 7 6

The two most frequently selected categories relate to Asian parents’ attitudes both to stuttering and to therapy, closely followed by clinic attendance, which could be seen as directly related to the first two categories. Categories concerning child rearing and family structure followed, with concern over referrals being the least frequently selected.

Table 8 gives details of data elicited under ‘other’, which, although low in frequency, show the wide range of potential factors which therapists may consider relevant.

STUlTERING THERAPY WITH BRITISH-ASIAN CHILDREN 333

Table 8: Therapists’ selection of aspects of therapy requiring special consideration - elicited under ‘other‘ categories

Aspects of therapy requiring special consideration as a result of cultural factors selecting aspect (other)

Number of therapists

Child-rearing ‘other’ High educational expectations Overcrowding in the home

Pressures associated with attendance at mosque Punished for stammering when reciting Koran Conflicting advice from community leader regarding stammer Child tired from attending mosque after school Linguistic pressure of learning English, Urdu Script and Koran (Arabic)

Total

General ‘other’ Non-fluency starting later than usual, i.e. after school entry when learning English as a second language Negative attitude of Asian male towards female therapist Social stresses of immigrant population Girls under pressure about stammer because of prospects for marriage

Total

5 1

11

5

DISCUSSION The majority (77%) of speech and language therapists working with Asian children/adolescents who stutter were shown in the survey (first paper) not to be specialists in stuttering clients. This characteristic of the population may have contributed to a lower feeling of success with stuttering clients in general. However, both specialists and non-specialists recorded lower levels of success with Asian clients than British, although 93% of the specialists recorded lower perceptions of success with Asian clients compared to 70% of non-specialists. The higher proportion of specialists perceiving poor success may be a reflec- tion of their experience at evaluating success with stuttering clients, or resulting from the fact that they have generally higher expectations of their success with stuttering clients regardless of their cultural background. This variable within the survey population, of experience with stuttering clients was therefore noted, but was not considered to have a significant effect on the results of the hypothesis testing on cultural issues.

The first hypothesis tested was that the percentage of Asian child and adolescent stutterers seen for speech therapy is higher than that warranted by Asian representation in the population. This hypothesis was framed from Lacey’s (1987) conclusion that her caseload of Asian children indicated a higher proportion than was warranted by their proportion in the local population.

Lacey also suggested that the relatively high number of Asian (Bengali) children in therapy may have been the result of cultural factors in their social envi- ronment which maintained stuttering. We have no empirical evidence


about Asian cultural values regarding child care, upward mobility, education or marriageability - factors that have been related to incidence of stuttering (Bloodstein, 1987). Nor do we have any evidence about the Asian community’s attitude to stuttering. However, the literature leads one to expect that there may be a higher incidence of stuttering, not particularly as a result of social factors, but perhaps caused by bilingualism (Karniol, 1992) and also because the Asian community is an immigrant ethnic minority - a social condition which seems to be linked with higher incidences of stuttering (Rohrlich Leavitt, 1974).

In spite of our expectations, however, therapists in this survey reported treating a lower percentage of Asian clients than that warranted by the percentage of the general population. As was pointed out earlier, the data on percentages of Asians in the population may be inaccurate, because of the National Census method of data collection. Even so, they are likely to be an underestimate of the true figures, and do not therefore affect the outcome of the hypothesis.

We cannot conclude from these findings that there is a lower incidence of stuttering in the Asian community, as comparisons were made between percentages of Asians in therapy and Asians in the general population. It is possible that the low numbers of Asians in therapy are not the result of a lower incidence of stuttering but rather of low referral rates, poor therapy take-up or failure to remain in therapy. All of these are possible, for example, referral rates may be low because of the difficulties for teachers and health visitors in identifying dysfluency in Asian children with limited English as a second language. It would also not be surprising if Asian families failed to remain in therapy if they were faced with inadequate interpreting facilities and underconfident therapists.

We can though conclude that Lacey’s (1987) findings of relatively high numbers of Asian children, and lower numbers of adolescents in therapy, are not repeated countrywide. The question remains as to why lower numbers of Asians are in therapy than can be expected by their proportion in the general population, and by their social situation as bilingual ethnic minority immigrants who may be at risk of higher incidences of stuttering.

The next issue addressed was whether therapists did in fact perceive their therapy to be less successful with their Asian stuttering clients than with their British ones. This hypothesis was overwhelmingly supported, with 75% of therapists confirming this to be the case. There can therefore be no doubt as to the continued need for research into this area. Perceived success may eventually be shown to be different from objective success. However, the perceptions of therapists are a vital part of service provision, because they reflect attitudes and levels of morale which can in turn affect service delivery. It is also of interest that Lacey’s (1987) belief that she was more successful with Asian adolescents than children was not replicated countrywide. The question therefore remains unanswered as to whether (as Lacey claimed) a reduced emphasis on family involvement tends to increase success in therapy, and also whether adolescents do in fact share greater cultural understanding with their British therapists - factors that Lacey believed may have contributed to her relative success.

In considering which factors may have affected therapists’ perceptions of


success in therapy, the data provided a number of surprising results. There appeared to be no relationship between larger Asian caseloads (and

therefore greater experience with this client group) and higher perceived success. Nor did therapist and client sharing an Asian cultural background appear to be a guarantee of higher perceived success. Although the literature indicates that therapist and client sharing a cultural background may lead to more effective health care provision (Spector, 1985), it must be remembered that within the cultural label ‘Asian’ there exists a wide variety of religious, cultural and linguistic variations. Detailed data on the range of Asian cultures were not elicited in this survey as the data would have become too fragmented and com- plex to analyse. It is therefore possible that the five therapists who described their cultural backgrounds as Asian did not in fact have the same religion, culture or language as their Asian clients. The culture gap may therefore have remained to a greater or lesser extent, explaining how two of the five Asian therapists recorded a lower perceived success with Asian clients.

All five therapists who had access to a satisfactory interpreter service also recorded lower perceived success with their Asian clients. This indicates that this important factor, alone, was not sufficient to lead to higher perceived success. This research did not consider the effects of combinations of variables, and it may be that a number of variables, for example, a good interpreter service, together with adequate training, and sufficient experience with Asian clients, may be necessary before therapists record higher levels of perceived success. It may also be useful for future research to investigate whether any higher success is perceived when working with bilingual co-workers rather than interpreters. In addition to their skills in interpreting and advising the therapist on cultural factors, the College of Speech and Language Therapists (CSLT, 1990) describes how bilingual co-workers should be competent in counselling clients and their families, a skill that is of particular relevance to stuttering therapy.

The two variables that yielded the most unexpected results were relevant postgraduate training and changes made to clinical practice. Both these factors were surprisingly related to lower perceived success in therapy. As we have no measure of therapists’ perceived success before training, it is of course possible that more of those therapists seeking further training had a feeling of lack of success initially, which prompted them to seek it out. This does not remove the fact, however, that the postgraduate training did not appear to raise their perception of success. One explanation for this may be that postgraduate training highlighted the possible pitfalls and lack of resources in this area, while leaving therapists acutely aware that they were unable to improve their services because of inadequate resources. For those therapists who did not have a particularly low perception of success before training, it may actually have precipi- tated a lower feeling of success by encouraging them to take responsibility for service failure upon themselves, rather than placing it with the Asian client.

As for those therapists who had chosen to make changes, they too were likely to have had initial low feelings of success which prompted them to make changes. Once again, however, it is of interest that making changes did not appear to raise their feelings of success. As discussed previously, it is difficult to quantlfy how effective the various changes were, although the survey results


(see first paper) reported a mixture of successful and unsuccessful changes. The one therapist who had made changes and did not record low perceived success described how she ‘worked very closely with an Asian assistant’, with the result that she ‘now managed to include parents in the treatment of their child with success’. Although this case provides only anecdotal evidence, it is of interest in that it relates both to the issue of working with a bilingual co-worker and to the results of the fourth hypothesis, which addresses the importance of effective communication and collaboration with parents if therapy is to be successful.

The fourth hypothesis identified those cultural factors therapists agreed on as requiring special consideration. Most frequently selected were Asian parents’ attitudes to both stuttering and therapy. These factors could also be seen to be related to the next most frequently selected category - attendance at clinic. Poor attendance at clinic would be understandable, if therapist and client failed to share the same view of stuttering and therapy, and particularly if they were unable to increase their mutual understanding as a result of a language barrier.

No single issue appears to be responsible for the low perceived success of stuttering therapy with Asian clients. It could therefore be hypothesised that it is the combination of variables addressed in this study which leads to so many therapists perceiving low success factors such as basic cultural differences in concepts of stuttering and therapy between therapist and client, inadequate interpreter services, and lack of training and experience on the part of the therapist.

One important question remains that has not been addressed by this research - that is how stuttering and the client/therapist relationship is viewed by the Asian client. This study has been carried out by a white British researcher into the problems of providing therapy to an ethnic minority client group. The next step must surely be to address the issue from the point of view of Asian clients and their families - to explore their views and feelings, an exer- cise which, in itself, may help to bridge the culture gap that seems to be indicated by this research.

ACKNOWLEDGEMENTS This research was funded by Rochdale Health Authority. The authors wish to thank the following: all the speech and language therapy managers and therapists who completed questionnaires, Juliet Goldbart and the referees for their constructive comments, Val Wilkes for preparing the manuscript.

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