The experiences of migrants to Australia who stutter

Purpose: Migration is a contemporary, global matter. With the number of international migrants doubling over the past four decades, speech-language pathologists will likely work with migrants who have childhood-onset stuttering. However, combined migration and stuttering experiences have never been investigated specifically. This study is the first to investigate the experiences of migrants to Australia who stutter. Methods: Three women and six men, aged 23 to 66 years old, participated. Data from individual interviews were analysed using Interpretative Phenomenological Analysis to examine the ‘lived experience’ of participants, as well as with NVivo 12 software for the management of coding. Participants also completed The Overall Assessment of the Speaker’s Experience of Stuttering


Introduction
Childhood-onset fluency disorder or stuttering is a speech disorder characterised by involuntary interruptions in speech, such as repetitions and prolongations of sounds, as well as blocks (Guitar, 2014). It may be accompanied by anxiety, or be exacerbated by certain environmental and/or personal stressors (Iverach & Rapee, 2014;Smith, Iverach, O'Brian, Kefalianos, & Reilly, 2014). The relationship between anxiety and stuttering can be significant especially for individuals with persistent stuttering (Alm, 2014;Craig & Tran, 2014), where it can have a negative impact on speech fluency, particularly during social interactions (Iverach et al., 2009). As a disorder of speech and communication, the negative impact of stuttering on the overall quality of life is well documented in the areas of developing self-esteem and interpersonal relationships, as well as in attaining education and employment (Yaruss & Quesal, 2006

Stuttering and migration
Managing mental health and stress levels are relevant in the context of stuttering. The modern definition of stuttering encompasses a whole-person perspective and emphasises links to the psychological impact of stuttering (Bloodstein & Bernstein-Ratner, 2008). Levitt (2009a, 2009b) reported that stuttering can be appraised as highly stressful. There have been advances in the knowledge of how individuals cope with stuttering (Plexico et al., 2009a(Plexico et al., , 2009b, and this information has contributed to the design and delivery of treatment programs for people who stutter. It is possible that the stressors associated with migration may increase functional impairment and may have an impact on the overall quality of life for people who stutter. However, little is known about migrant individuals who stutter, including their experiences of the process of migration and how they cope with stress associated with migration.
Common themes of stress affecting the development of identity, mental health and life achievement, and the importance of social networks and community participation for positive outcomes, can be seen in both migrants and people who stutter. However, there is currently a gap in the literature relating to the combined experiences of migration and stuttering. It is of importance for clinicians working with people who stutter to understand the issues of migration in combination with stuttering, namely, its potential impacts on social participation and wellbeing.

Research aims
The research aimed to explore (a) the experiences of migrants to Australia who stutter, (b) any impact of stuttering on the process of migration and vice versa, (c) any facilitators of the migration process and/or the management of stuttering, and (d) comparisons of living with a stutter between Australia and the participant's country of origin. There were, however, more specific questions that stemmed from these broad questions. There were no exclusion criteria regarding participants' countries of origin, the reasons for migration, at what age they migrated, or if they spoke languages other than English. This allowed for further exploration of the experiences of migrants who stutter and who also (a) speak English as an additional language, and/or (b) identify with different cultural background(s).

Material and methods
The research received ethics approval through the Edith Cowan University Human Research Ethics Committee and written informed consent was obtained from all participants. All names of participants used in this report are pseudonyms.

Participants
Nine adults who stutter were recruited via convenience sampling through a local community support group for people who stutter. Participant eligibility criteria included (a) a clinical diagnosis of stuttering by a qualified SLP, (b) having moved to Australia from another country, (c) being 18 years of age or older, (d) having sufficient skills in English to participate in the interview without the need of an interpreter, and (e) not having a comorbid condition (i.e., not also having a concurrent diagnosis of psychosis, intellectual disability, or any neurological condition) that could potentially distract from the research topic.
Three women and six men who stutter participated, with an age range of 23 to 66 years (M = 40.2y). All participants reported a childhood onset of stuttering, in line with the profile of persistent developmental stuttering (Guitar, 2014). Three participants migrated from the United Kingdom (UK) as their home country, two from India, and one originally from France who lived in the UK immediately prior to arrival in Australia, with the remainder from the Asian countries of Afghanistan (via Pakistan), Sri Lanka and Nepal. There was one refugee in the study, who was from Afghanistan, while all other participants moved to Australia for economic reasons.
There was a wide range of the number of years spent in Australia, from 2 to 63 (M = 13.8y). Seven participants had been in Australia five years or more with only two participants arriving recently, approximately two years ago. The participant from Sri Lanka moved as a young child and had been in Australia for 63 years; this length of time is much higher than all of the other participants. Excluding this participant, the mean duration in Australia was 7.6 years. Four participants reported English as their first language and five participants spoke English as an additional language.

Stuttering severity and quality of life
To gain a better understanding of the stuttering profile of the participants, a measure of the impact of stuttering on quality of life using the Overall Assessment of the Speaker's Experience of Stuttering (OASES: Yaruss & Quesal, 2008) was collected. The overall impact score ranged from 1.54 (mild) to 4.2 (severe), with a mean rating across all participants of 2.58 (moderate rating according to the OASES™).
In addition, the recorded interviews were used to rate stuttering severity using a 9-point perceptual severity rating scale. The scale has been shown to be a reliable indicator of stuttering severity and in correlation with percent syllables stuttered measures (O'Brian, Packman, Onslow, & O'Brian, 2004). A rating of 0 indicated no stuttering, and 8 indicated extremely severe stuttering. The first and second author, both SLPs, independently assessed the samples and took into consideration a number of factors and characteristics of the participants' speech to assess how much stuttering interfered with the message getting across (O'Brian et al., 2004). This included stuttering behaviours exhibited by the participants such as the type, rate, and duration of individual stutters, overall speaking rate as well as naturalness of their speech.
In order to account for potential fluctuations in stuttering severity during the interview, assessors listened to a minimum of 15 min of each interview, which comprised three samples of at least five-minutes each of the start of the beginning, middle, and final third sections of each interview to judge overall stuttering severity. A reasonable agreement was defined as a difference of no more than one scale value between the two assessors, and this was achieved for all interviews. An average of the two ratings determined the resulting score for each participant.
Results suggested mild to moderate stuttering severities. Six out of nine participants produced all types of stuttering behaviours; repetitions, blocks and prolongations. Eight out of nine participants produced blocks in their speech. Sabrina was the only participant who did not exhibit blocking or prolongations, and her stutter was characterised by repetitions of sounds, words and phrases. Matt and Patrick spoke with a marked reduced speech rate and used salient speech restructuring techniques. Table 1 contains a summary of participant demographics, OASES™ impact score and stuttering severity scores.

Interviews
Individual, face-to-face semi-structured interviews were conducted to facilitate in-depth descriptions of the participants' experiences and enable a rich representation of experiences (Converse, 2012). The methodology of semi-structured interviewing was selected to elicit the experiences of people who stutter (Anderson & Felsenfeld, 2003;Corcoran & Stewart, 1998;Hearne, Packman, Onslow, & Quine, 2008;Plexico, Manning, & DiLollo, 2010). Interviews were conducted and digitally recorded by the second author, a qualified SLP at a quiet location convenient to the participant. Prior to the interviews, case history forms and the OASES™ were completed. Case history forms contained questions about the participants' backgrounds, migration to Australia, languages spoken, and past stuttering therapies. Interview durations ranged from 36 min to 1 h, 18 min, with a mean duration of 54 min. Sufficient time was given to all participants to allow for appropriate exploration of the topic. Probes were used where necessary to encourage deeper reflection of topics of interest or identified importance to the participants.
A broad topic guide with interview prompts was prepared based around the research aims. The interview structure is presented in Appendix A. If participants indicated that they spoke a language or languages other than English in their case-history forms, further probes were used to elicit more detail. In addition, interviewees were free to focus on issues most prominent to them (Birks & Mills, 2011;Hammersley, 2013). After each interview, field notes were made on question sheets contemporaneously and were used to aid transcription and data analysis. The field notes included documenting relevant answers, quotes, and observations.

Data analysis
Interviews were transcribed verbatim by the fourth author and transcripts were uploaded to the NVivo 12 qualitative analysis software program (QSR International, 2018) to aid in thematic analysis. The accuracy of the transcripts was checked independently by the first and second authors.
Data analysis utilised Interpretative Phenomenological Analysis (IPA) to examine, in detail, the participants' personal 'lived experiences' and how they made sense of that experience (Smith, Flowers, & Larkin, 2008). This process was iterative and inductive. The initial stage required the researchers to be immersed in the original data. This involved a process of reading and re-reading the transcripts and listening to the recordings of the interviews to acquire a primary perception of the experiences described by each participant. Observations, descriptive comments and thoughts pertaining to language use and content of the transcripts were noted as annotations and memos using NVivo 12 software. Initial, broad themes emerged from this process. Following this, analytic comments were made to determine the final themes (Osborn & Smith, 2008). The first, second and fourth authors conducted the analysis of the transcripts and derived initial themes independently. In order to establish procedural rigour, each researcher produced audit trails including memos and annotations of the data using NVivo 12 software during data analysis (Kitto, Chesters, & Grbich, 2008). This audit trail included a record of reflections, emotions, thoughts, and questions from the researchers, which helped to recognise any bias that may influence interpretation. It also provided information regarding thought processes behind any conclusions and interpretations drawn from the data (Tuckett, 2005).
Meetings were conducted to discuss notes and observations, as well as to revise themes derived from the interviews. Importantly, investigator bias was mitigated through researcher reflection, maintaining a clear audit trail, and detailed discussions during meetings held with the first, second, third and fourth authors (Levitt et al., 2018). The third author, also a SLP and qualitative researcher, who was not present at the interviews and did not complete initial analysis of the interview data, was able to question findings and interpretations of the other authors. For each difference, possible reasons were identified, and researchers then collectively reviewed and determined the most unbiased finding and interpretation through agreement of all researchers at the meetings.
The process of data analysis continued throughout the writing of the final paper, and further refined the themes, as writing is in itself a process of reflection and evaluation (Van Manen, 2016). As part of the member-checking process, a final synopsis of the study's main themes was sent to the participants to confirm that the researchers had accurately represented their perspectives. The feedback received from participants was positive, and there were no comments that involved changes to the researchers' main themes. This method of member checking was used to provide research interpretations with credibility (Ryan-Nicholls & Will, 2009).

Major themes
Stuttering was an innate facet of participant self-identity, and as such, could not be clearly removed from any experience they encountered. Notwithstanding, a number of experiences and factors relating predominantly to migration were identified. Four central themes, representing the framework within which participants described their experience of being a migrant who stutters, emerged from analysis of the transcripts. These themes provide the basis for the theme: how the stresses, experiences, and factors interacted to shape the overall experience of being a migrant to Australia who stutters. Processes, strategies, and aides that facilitated coping mechanisms were also discussed. The themes are: • stuttering defining the sense of self; • challenges with fitting in and settling; • compounded stress from migration and stuttering; and • facilitators of change, acceptance, and transition.

Stuttering defining the sense of self
Stories of growing up were useful to gain insights into participants' belief systems and expectations. The overarching theme was that stuttering was, and still is, a negative aspect of the participants' lives, as indicated by OASES™ impact scores of 'mild/moderate' to 'severe'. Stuttering was often harmful, caused distress, and resulted in lack of self-confidence and poor sense of self. Six participants associated stuttering with feelings of stress and anxiety, and five participants mentioned an associated low sense of self-worth. Patrick said, "it did actually hinder me in so many ways. A person who hasn't got any self-confidence, just curls up in a ball and just tries to get through life". Experiences with stuttering were observed to be pervasive and entrenched in many aspects of the participants' lives relating to the development of self-identity, interpersonal relationships, as well as impacting on decisions about career and life.
Participants tended to refer to stuttering in terms of its secondary effects, rather than their speech fluency itself posing as the barrier to communication. Even when the individual was overtly fluent, fluency-related barriers were present. Participants spoke about the threat of stuttering being associated with increased levels of anxiety. This is in accordance with OASES™ impact and stuttering severity scores, whereby seven out of nine participants were rated to have lower stuttering severities in comparison to their OASES™ quality of life impact scores. Shivesh exhibited the greatest discrepancy with a 'mild-moderate' stuttering severity rating and a 'severe' OASES™ impact score. Greg and Patrick were the only participants with lower OASES™ impact scores, both scoring 'mildmoderate', than their stuttering severity ratings, both rated as 'moderate'.
Many participants endeavoured to avoid and reduce stuttering behaviours as much as possible, and the constant burden they experienced in relation to controlling their own speech was demanding on cognitive resources. Jabar's decision to remain silent, rather than speak and risk ridicule, was more of a burden as he regretted being unable to express himself. Also, participants reacted negatively to others bringing attention to their stutters, further illustrating that attention to stuttering was perceived as a barrier to communication.
The general lack of awareness of stuttering and negative community attitudes toward people who stutter were a source of stress for most participants. All participants shared experiences and feelings of frustration due to the perceived misunderstanding of stuttering from members of their family, friendship circle and/or society regardless of their country of origin. Patrick (UK) felt that stuttering as a health condition was "brushed under the carpet" and that "it's not seen as a real disability… not seen as important" in both UK and Australia. Laatri did not find it useful that her employer in Australia described her stutter as an "idiosyncrasy rather than [a] disability". She had the opinion that if stuttering was recognised as a disability there would be more awareness about it. Participants also expressed frustration toward the lack of access to services for their stuttering in their countries of origin and in Australia.
Experiences of discrimination related to stuttering, particularly in the school setting, was a recurrent theme and shared by all participants. School-aged experiences were mostly reflective of the participants' home countries since eight out of nine participants moved to Australia as adults. Melanie described growing up with stuttering in France to be "really emotionally painful…almost traumatic really, also being mocked by all the kids at school". Patrick from the UK said it was a "very, very hard childhood, absolutely. Got teased, heckled a lot, being called names at school just eats away at your confidence". Shivesh shared an interesting story where he was discriminated in the workplace by co-workers in India and his case was heard in court. The judge ruled in his favour but he was unable to return to that workplace due to feeling traumatised by the experience. There were also examples of discrimination and teasing in the family unit for two participants who migrated from Asia, Sabrina and Laatri. Laatri said it was an extended family member who first placed pressure on her to do something about her stutter as it was seen to be negatively impacting on her family's reputation in her hometown.

Challenges with fitting in and settling
All participants had expectations of a better life before arriving in Australia, however this was associated with feelings of uncertainty and pressure for some participants. In particular, for participants coming from Asian countries such as Nepal and India, they described initial perceptions of Australia to have had better opportunities for their careers. Participants from the Asian countries also described increased family and societal pressures. Manav said, "I come from a middle-class business family, being the eldest son there was lot of pressure on me". Sabrina, who migrated as a young child from Sri Lanka in the 1950s, reported feeling like a perpetual visitor and spoke of an associated pressure to fit in. Her grandmother sponsored her family's move to Australia and this had a major influence on her beliefs and actions, saying "we were new Australians… don't rock the boat… don't cause trouble". She felt that having a stutter brought negative attention to the family.
Sabrina and Melanie both had a deeply ingrained feeling of responsibility to "become Australian and to fit in". Melanie (France and UK) confirmed that the feeling of responsibility to adapt to the culture of her new hometown was a contributor to her stress levels, "I'm trying to become Aussie, that's what I should be doing and all immigrants should be doing when we move to a new country… adapt to the culture and become like the people there, the locals".
Participants found the differences associated with moving to a new place of residence were difficult to navigate. Eight out of the nine participants spoke about their environment being very new and unfamiliar and that this impacted on their feelings of stability in their new home. Seven participants acknowledged an increased level of stress particularly when they first arrived in Australia. Jabar stated, "it was very hard the beginning… being amongst different people, different language". Shivesh arrived in Australia two years earlier, sharing the most recent arrival along with Matt from the UK. At the time of being interviewed for this project, he described that he was experiencing an increased level of stress due to difficulty with securing work in his area of qualification, attributing this to having a stutter. He scored the highest severity score on the OASES™ with a 'severe' impact score, stating "I never felt so stressed". Melanie had lived in two other countries before moving to Australia, and despite this, found that moving to an unfamiliar place made life very complicated, and said, "so at first moving to a new country where everything is different… is very stressful".
The factors surrounding the perception of increased stress were at times described broadly as 'cultural' differences. For example, Manav said that "it was a big cultural shock… first six months I was regretting why did I left (sic) my country". Specific factors contributing to perceived levels of increased stress upon arrival to Australia were often associated with a combination of aspects including the need to secure employment, to develop new social networks, and to deal with differences in language or accent.
The physical separation from former support networks and the daunting reality of not knowing anyone led to increased feelings of isolation for seven participants. Five participants specifically mentioned challenges with securing employment in Australia. Laatri faced challenges with having to find work in a regional area, a requirement of her visa. Melanie reported that the stress associated with difficulty finding work on arrival was also associated with differences in language and accent: "when I first came with the working holiday visa, my English wasn't so good…and my French accent was very, very strong".
In addition to Melanie, five other participants also faced issues with English being an additional language and/or having an accent that was different to the majority of Australian speakers. Laatri expressed that, "when you come to a new land, when you're struggling because of the English, I was struggling". Greg and Sabrina described difficulties with their accents being different to mainstream Australian speakers even with English as their first language. Sabrina from Sri Lanka, who described herself as a Dutch Burgher, said she had trouble fitting in because of her accent, saying "you get sick of people asking you, 'Why (sic) you talking like that to your Mum'?" Manav was the only participant who reported an incident of racism, a significant story for him that impacted him greatly. His neighbour overheard him speaking with his wife at home in his native language and vilified him for it.
Patrick, from the UK, was the only participant with no specific examples of increased stress during migration. His decision to move to Australia coincided with the time he had successful stuttering therapy in his home country, saying "if I hadn't had the training that I had with my speech, I don't believe I would have done it". He scored the lowest impact score on the OASES™ with a 'mild/moderate' score (1.54). Greg, also from the UK, was largely positive about his move to Australia, and said that "I mean when I came here, I didn't find anything negative really, it was obviously a fairly exciting time as well". Yet, the newness was stressful in the context of Greg's career.

Compounded stress from migration and stuttering
Seven participants described stories of uncertainty and increased stress during their migration to Australia and that this led to difficulties with stuttering, speech and/or communication. The participants' stories revealed that the stress related to migration generally increased the stress associated with stuttering. For example, migration increased stress in general for Melanie who said, "when I am always stressed, I stutter more than when I'm not. So, at first moving to a new country where everything is different language… look for a job… accommodation, so it's quite stressful".
The specific factors that impacted on stress and stuttering were identified as previously mentioned stressors associated with the migration process: finding work, meeting new people, and dealing with language and cultural differences. For those who spoke languages other than English, the use of a not-yet-dominant language was an added stressor. For Laatri, a language difference was the main reason for a perceived increase in stuttering. She described that an increase in cognitive load from having to remember English words resulted in an increase in stuttering disfluencies in her speech.
Eight participants spoke of how seeking employment was negatively affected by their stutters. Manav and Shivesh moved with the hope of better work prospects and believed they could have achieved more in their careers if they did not stutter. Melanie felt that her stutter had made it more difficult to "become an Australian", by impeding her ability to form friendships and secure employment saying, "no-one wants to hire someone who stutters".
The loss of social networks as a result of migration was expressed to be a factor that impacted on stuttering by seven participants. Shivesh reported that moving to Australia was associated with an increase in stuttering severity due to the loss of his support network and some negative reactions he experienced in response to his stuttering. He stated that this resulted in loss of self-confidence and further impacted on his ability to find work in his field. Matt came to Australia from the UK with the intention of being a temporary visitor but had since become engaged to an Australian local. He found that social isolation impacted on his stutter: "you're interacting with new people and they don't know you stammer so that was hard to begin with". Matt and Patrick both used strategies that they had learned from a specific program in stuttering in the UK that is not available in Australia: The Starfish Project (http://www. starfishproject.co.uk/). They both commented on how they felt that moving to Australia resulted in challenges because of the loss of the support network for this particular program.
Migration-related factors often interacted with stuttering across more than one area of the participants' lives. For example, Manav stated that Australia was a new place for him, where he had no friends or family for support and was having to deal with cultural differences. He explained that his stutter was more severe with meeting new people, and that social isolation resulted from his fear of negative judgement in such situations as well as not allowing time to connect and interact with others due to a focus on work: "building your career, you get socially isolated and that also contributed to my stutter".
During the initial stages of migration, Jabar's traumatic migration history had a significant negative effect on his quality of life and ability to cope with stuttering. He had to deal with a multitude of traumas and stresses in his home country of Afghanistan, during his escape to Pakistan and finally when settling in Quetta. However, at the time of the interview for this project, he had reflected that moving to Australia gave him the opportunity of "starting life from zero". As time went by, he was able to focus on improving his stuttering and communication skills by developing a more positive perspective on stuttering, attributing a positive frame of mind to living in Australia, a 'safe' country. He scored the second lowest impact score, 'mild-moderate' on the OASES™.

Facilitators of change, acceptance and transition
As adults, all participants had undertaken some form of therapy to target stuttering behaviours either in their home countries and/or in Australia. The majority of participants had received therapy in their home countries with six of the participants readily employing speech restructuring techniques learned in therapy to help control their fluency. At the time of the interviews for this study, none of the participants were actively engaged in formal therapy or support groups for people who stutter to target stuttering.
Some participants went to significant efforts in order to access treatment including Greg, who travelled overseas from Australia and paid a large sum of money to obtain an altered auditory feedback device to help him manage his stutter. Similarly, Shivesh borrowed money from a friend and undertook a long cross-country journey in India, by train, to access a "cure" for his stuttering.
Past therapies among the participants varied considerably. Therapies based on traditional beliefs were mainly observed for participants from Asian countries, Nepal and India, where therapies were largely delivered by non-professionals, and/or had nonspecific targets/strategies to target stuttering. For example, as a teenager, Laatri received therapy in Nepal and her therapist "pretended he didn't notice (the stutter)" to distract her from the problem. However, interestingly Patrick from the UK mentioned that, as a teenager, he had "grapes in the mouth, and stones in the shoes" as a form of treatment for stuttering.
The participants commented on how they perceived therapy in Australia to be more holistic in nature when compared to services in other countries. Therapy available in Australia was reported to focus more on the psychological aspects of stuttering as a more viable form of therapy in conjunction with speech modifying techniques, whereas countries like India and Nepal tended to focus more on the fluency disruptions through modified speech alone. Manav felt that therapies in India were more impairment-focused with no consideration of the emotional aspects of stuttering.
Seven participants believed that it was important to consider the psychological aspects of their stuttering and self-acceptance in order to improve their fluency and quality of life. Patrick spoke about an occasion where an attempt to use fluency techniques became visible to bystanders. He explained to them what he was doing and laughed it off, feeling less traumatised as a result. For Melanie, stuttering was both an emotional and a physiological experience, and she subsequently found that input from both a speech pathologist and a psychologist was valuable for her management. Many participants described a process of self-help to manage their stuttering that involved conscious regulation of their attitudes, self-esteem and confidence. Having a positive attitude was regarded by some participants to be beneficial. Participants described meta-analysing their circumstances and re-framing difficulties with a more positive perspective, or persistence, in the face of adversity. For example, Jabar echoed this when he encountered a homeless man with a disability, using this example to put stuttering into perspective and that he need not react negatively or be too concerned with stuttering. Greg believed that a positive frame of mind had helped him in his therapy, saying "don't think of it as such a big deal".
In the context of migration to Australia and the management and coping with stuttering, all participants spoke about how they perceived Australian society to be an accepting place. In comparison to participants' home countries, views and attitudes toward stuttering in Australia were more positive. Shivesh did have some negative perceptions of Australian as a society saying that "they expect you to be more confident and fluent here, so in Australia you feel some social pressure to be a certain way". Also, Sabrina who grew up in Australia after migrating as a young child from Sri Lanka did not have much to say about differences between the two countries, whereas the other participants described Australian people as "outgoing", "relaxed", "patient" and "easy-going".
While Shivesh and Manav acknowledged that they did not feel supported in Australia due to the loss of their family and friendship circles, they still considered that as a society, Australia was more accepting than India. "In India, when I was working and I used to stutter, my boss used to tell, in front of like fifteen people, 'look at this guy, he's stuttering, how will he do his job?'", said Manav. Manav added: "employers in Australia, they understand in someone's disability, they never exploit it, they always try to give confidence". Also, Laatri (Nepal) said, "back home, people are not nice, family and society…Australia is more supportive".
All the participants from the UK also shared positive comments about Australia. "In my experience, I can't say I've had a bad experience over my speech over here, can't say that about England", said Patrick. Matt reported: "back home, they would try and like finish your words or finish your sentence, not so patient". Greg said, "a good thing in this country that it is fairly culturally diverse so that helps us be sort of open. Here it's a bit more laid back…".
Furthermore, circumstances that prevented or impeded one's ability to achieve a positive frame of mind were perceived to be barriers to successful management of stuttering. For example, Matt, a UK army officer who had served in Afghanistan, highlighted that his experiences with being in a hostile environment impacted on his ability to concentrate on his speech "because you're thinking… a million miles an hour about what's coming up and what's happening". Jabar stated that the security associated with being in Australia enabled him to feel safer, and allowed him the peace of mind to concentrate on self-improvement with regard to his stutter. Jabar described vivid experiences of how he feared for his physical safety saying, "I just made it… I just suffered a lot… very amazing it's like good to be alive now". This physical trauma was linked to his stutter. He illustrated this by saying he had a fear of other men due to atrocities he witnessed first-hand perpetrated by men, but with women he felt safe: "Anyway, now I see a lot of males everywhere…I don't know but this is in the back of my head… like I just still fear. I don't stutter [with women] I feel more comfortable".
Lastly, all participants noted that maintaining social relationships was important to combat negative feelings of stuttering. Shivesh shared that when his landlord in Australia offered to take him to karaoke to help him with his stutter, it helped to make him feel supported enough to open up about his difficulties. In addition to informal support networks, all participants expressed an appreciation for the help provided through more formal community support networks that facilitate contact with others who stutter. All participants had engaged with a community support network for people who stutter. Greg and Melanie felt accepted and understood when they were able to be around others who stutter. Matt and Patrick found the support group useful as an opportunity to practise fluency techniques, although they did comment that the techniques that they used differed to those commonly used in Australia.

Discussion
The current study is the first to explore the experiences of migrants to Australia who stutter. Participants were free to discuss issues and experiences relating to migration in a broad sense. Using an interpretative phenomenological analysis approach, we found that participants' experiences had often centred around the concepts of psychological stress (Lazarus & Folkman, 1984) and identity (Hammack, 2015). The results demonstrate that the stresses of migration and stuttering interact and adversely affect an individual's perception-of-self as well as on their overall quality of life (Craig & Tran, 2014;Iverach & Rapee, 2014).

Perception-of-self and sense of belonging
Considering culture and personality are developed through childhood experiences and socialisation (Bhugra, 2004), it was interesting that all participants had shared experiences despite coming from a range of different places. There was a common psychological element to their stuttering which formed a core component of their identities (Nang, Hersh, Milton, & Lau, 2018;Plexico et al., 2009aPlexico et al., , 2009b. Stuttering appeared to impact on the socially based self-perception and identity construction for the participants in this study (Corcoran & Stewart, 1998;Crichton-Smith, 2002).
Living with a stutter was connected to participants' overall thoughts, beliefs and behaviours, and while these were uniquely expressed for each participant, there were elements that were common to all. This included the negative psychological implications of growing up with a stutter, often leading to lower self-esteem and lack of self-confidence; similar comments were also made by Carter, Breen, Yaruss, and Beilby (2017) and Plexico et al. (2009aPlexico et al. ( ), 2009b. Such feelings were prevalent during school years, a crucial time for identity development (McLean & Syed, 2015), as well as later in life in the workplace. Participants expressed the importance of targeting the psychological aspects underlying their stutters, including their perception-of-self, in order to manage stuttering.
Participants expressed frustration towards the perceived lack of general awareness and understanding about stuttering, and considered this to be a barrier to their management of stuttering. Although these comments were mostly in relation to their home countries, some comments were made about Australia such as perceptions about the lack of awareness of stuttering in employers. Therefore, the findings suggest a need for further work to understand and accept the attitudes, awareness, and visibility of stuttering as a communication disability, as suggested by Pillay (2013).

The stress of migration and stuttering, and how they relate
Most participants found the prospect of moving to Australia exciting, and most also felt positive about living in Australia. The one exception was Shivesh, who was experiencing a high level of stress at the time of the interview, to the point of feeling regret of moving to Australia. Nevertheless, eight out of nine participants described how migration to Australia was at times stressful and that this had an impact on their stuttering. In line with other studies in migration, the period soon after arriving in Australia or the initial stage of migration was particularly stressful (Bhugra, 2004), and an increased level of stress was associated with increased uncertainty in living circumstances as well as adapting to the new environment (Ballas & Dorling, 2007).
Participants responded in varied ways to deal with the stressors of migration and settling into life in Australia. The data suggest that the participants' migration-related stressors and stuttering-related stressors were linked, and the interaction of the stressors was bidirectional and changed over time. For example, several participants described that the experiences of increased stress with migration led to negative effects on their stuttering, resulting in an increase in functional impairment and a reduced ability to cope with stuttering. In contrary, Patrick's story is demonstrative of how positive feelings associated with stuttering prior to moving had contributed to a more positive migration experience. As the only refugee in the current study, Jabar's story was unique due to the traumatic events that led to his journey to Australia. However, his experiences also demonstrate a link between migration-related stress and stress experienced with his stuttering. Initially, migration-related stress was high, which impacted negatively on his stutter, but over time when migration-related stress decreased, his stutter improved.
We refer to the psychology literature to discuss how and why migration is linked to stuttering. The human coping response usually involves a combination of cognitive, affective, and behavioural processes, and there are a number of individual factors that influence the cognitive appraisal and management of the stress (Lazarus & Folkman, 1984). Cognitive appraisal is a set of processes whereby individuals make a judgment about whether a situation is stressful (Lazarus & Folkman, 1984). Migration and stuttering can both be stressful situations that compete for finite resources as the stressors underlying migration are also relevant to stuttering.
The broad management of stuttering in addition to the moment-to-moment control of stuttering during communicative exchanges with others can be considered cognitively and emotionally demanding (Plexico et al., 2009a). There is evidence to indicate that stuttering is impacted by limitations in cognitive resources, attentional regulation (Smits-Bandstra, De Nil, & Rochon, 2006), and emotional regulation (Karrass et al., 2006). In addition, for people who have chronic stuttering and use speech restructuring or other fluency techniques, there is also a need to consciously implement the techniques, and it is well known that mastery of these skills is challenging and particularly prone to relapse (Craig, 1998). Therefore, increased stress experienced with migration-related circumstances can impact on an individual's ability to focus on stuttering management.
The need to communicate clearly and confidently in order to find a job (Klein & Hood, 2004) and to meet and connect with people in a new country, are exactly the areas that stuttering impedes upon. Together, the stresses of migration and stuttering can have a detrimental impact on an individual's quality of life. For example, a lower proficiency in English was a key migration-related stressor, and combined with stuttering made communicating with others even more difficult. Proficiency in the dominant language has been found to be a crucial component of structural and social integration of immigrants, because it enhances social networks with the majority community and improves employment and income opportunities (Chiswick & Miller, 2001;Guven & Islam, 2015).

Impact of migration on the perception-of-self and sense of belonging
The migration-related stressors reported for this study were associated with factors that resulted in the perception of feeling 'different' in comparison to mainstream Australians. Migration had emphasised differences in communication ability, race, and ethnicity, and such differences were found to hinder an individual's ability to navigate the new environment, to secure employment, and to meet new people. Identity is the anchoring concept for thinking about difference and sameness at the levels of social categorisation, group affiliation, and intergroup relations, as well as of individual consciousness or subjectivity (Hammack, 2015). The concept of self or core identity is already a sensitive aspect of the lives of many people who stutter (see also, Nang et al., 2018;Plexico et al., 2009aPlexico et al., , 2009b. More specifically, all five participants, who spoke English as an additional language, considered that having limited English was a barrier to 'being like everyone else', a common feature of the experience of a migrant (Müller, Kamcili-Kubach, Strassheim, & Koch, 2012). Also, there were comments about differences in accent for some participants who had English as their first and only language. This finding demonstrates that any difference in communication was perceived to be a barrier to fitting in, which can then result in a negative migration experience (Stevens, 2010).
In summary, the data suggest that a migrant dealing with cultural differences could be at higher risk of experiencing conflict with their self-identity. The findings support those in the literature relating to discrimination based on disability and ethnicity (Stevens, 2010), access to occupational avenues (Mirza, 2012), and social exclusion (Albrecht et al., 2009). The participants who migrated from Asian countries described increased pressure to succeed as well as increased stress with migration in comparison to the participants from the UK, where migration occurred without major language or cultural differences. Two participants from the UK, who reported largely positive migration experiences, spoke English as their first language and were also Caucasian. Similarities in the language and ethnicity, as well as easier access to socialisation, are hypothesised to have supported a positive self-identity and a sense of belonging for these participants (Bhugra, 2004). The smaller cultural differences arguably allow for better adaptation to the receiving culture in Australia (Berry, 2005).
Gender is a possible contributing factor for the more positive migration experiences of the men from the UK. Gendered differences have been reported in the area of stuttering where it was found that the experiences of women who stutter were shaped by cultural expectations of women in society (see also, Nang et al., 2018). However, there were too few participants in this study to draw firm conclusions about how gender impacts on migration experiences. Interestingly, two of the three women described pressures and a responsibility of having to 'fit in' and adapt to the Australian way of life, whereas none of the men in the study expressed the same pressures. It is possible that the women had more of an entrenched need to feel that they belonged and to not draw attention to themselves. There is some evidence to support that women may perceive stresses associated with migration differently to men. Müller and Koch (2017) reported that female migrants had a higher global stress level compared to male migrants in Germany. The authors hypothesised that this may be due to differences in stress perception and adaptation, citing that women have a higher risk for developing depression and anxiety disorders than men.

Coping with the stress of migration and stuttering
The task of managing stuttering is particularly challenging when coupled with having to deal with as the stress of migration, and managing a new language and culture. Coping varies depending on resources available to that individual (Lazarus & Folkman, 1984). Resources can be (a) internal, such as personal characteristics including beliefs, commitments, and psychological resilience; or (b) external, for example, social support.

Social support and acceptance
There were facilitators to coping with stuttering that were relevant to participants' experiences during the migration process. Participants spoke of a number of different coping mechanisms that they employed to deal with the many stressors associated with their stuttering. In line with other studies of mechanisms for managing stuttering (Plexico et al., 2009b), the participants in the current study self-regulated their emotional response through positive thinking and exploration of the psychological basis to their stuttering. However, a unique finding of the current study was that a prominent facilitator to coping with stuttering was the 'acceptance' of stuttering by the Australian society. All participants regarded Australia as more accepting of their stutters than their home countries, and described Australia to have a better understanding of, and more positive attitude toward, people who stutter.
Therefore, it is hypothesised that the stigma and negative stereotype of stuttering (see also, St Louis & Tellis, 2015) is a barrier to successful management of stuttering, and such factors are likely to have played a role in experiences of discrimination that the participants endured because of stuttering. It may be fruitful to explore in future studies, intervention to target changing negative attitudes about stuttering in fluent individuals. To date there has been a handful of studies investigating this, but they have yielded inconsistent results (see Abdalla & St Louis, 2015). Boyle, Dioguardi, and Pate (2016) reported positive outcomes for the use of antistigma strategies in people with no communication disorder, for reducing negative stereotypes of people who stutter.
The perception of more acceptance in Australia for the participants in the current study may perhaps have a reflection of more contemporary attitudes of stuttering in comparison to past attitudes of stuttering, as most of the childhood stories of stuttering were of a considerable time ago. Nonetheless, even the younger participants, in their twenties, shared similar stories and agreed that Australia was more accepting than their home countries.
Related to the concept of acceptance, all participants expressed that support networks were central to their ability to settle into life in Australia. To help combat feelings of increased isolation and loss of previous support networks (Bhugra, 2004;Cochrane, 1983), they had all reached out to engage with a support group for people who stutter. While the data are limited, the role of community support groups for people who stutter have been reported to be beneficial in the management of the psychological aspects of stuttering (Boyle, 2013;Yaruss et al., 2002), and comments from the participants in this study contribute to these previous studies.
The importance of the support network was found to not only be beneficial for the management of stuttering, but also beneficial for forming new relationships, particularly for the migrants with little or no contacts in Australia. The role of social support for improved health outcomes is well recognised in a number of disciplines (Cohen, 2004). Community support groups have been found to assist a sense of belonging for migrants with a disability and play a role in preventing social isolation (Albrecht et al., 2009;Mirza, 2012), as well as helping to prevent depressive symptoms in migrant refugees (Bhugra, 2004).

Resilience
Our interpretation is that the participants in this study have shown resilience in order to overcome significant barriers associated with stuttering in order to pursue and achieve life goals. Resilience, defined as "a class of phenomena characterised by good outcomes in spite of serious threats to adaptation or development" (Masten, 2001, p. 228), has been an area of interest in stuttering research, with findings indicating that resilience facilitates the successful management of stuttering (e.g., Carter et al., 2017;Craig, Blumgart, & Tran, 2011). The relationship between resilience and stuttering has also been explored, with positive correlations identified between locus of control of stuttering, social supports and interaction, and feelings of success in coping with adversity related to stuttering (Craig et al., 2011). Recently, Plexico, Erath, Shores, and Burrus (2019) reported that a lower level of resilience was associated with diminished self-acceptance and quality of life for people who stutter.
The decision to leave a hometown and move to a new country is no small feat for any given individual. Bhugra (2004) suggests that at the level of pre-migration, concepts of self, psychological, social, and biological vulnerabilities, may play a role in influencing subsequent experiences of migration. Therefore, despite the adversity of growing up with stuttering, the participants in this study pursued the challenge and were committed to moving to a new country. This may not be as applicable to Sabrina who moved as a young child, but for the remaining participants, including Jabar, there was likely a belief and hope that it was possible, and they made the commitment to giving it a go.
Being able to ask for help when in need is a trait of resilience (Masten, 2001), and coping as a migrant has been associated with accessing informal support, through family and friends, as well as formal support (Roberto & Moleiro, 2016). Such factors have also been cited to be facilitators to the successful management of stuttering (Craig et al., 2011). Accessing external support is a reflection of increased self-awareness among the participants, that is, they had identified that they needed help. The participants responded with a problem-focused coping method (Lazarus & Folkman, 1984), whereby individuals displayed agentic behaviour and selfefficacy to seek and engage with external support. At the same time, upon investigation of the participants' OASES™ scores, 69% of the participants had an overall impact score of 'moderate' severity or higher, and no participants scored 'mild'. In contrast, 78% of the participants were considered to have stuttering severities that were 'mild' to 'mild/moderate' with no participant having a 'severe' rating. This highlights that even though participants presented with less severe functional impairment, the impact of stuttering on their lives is significant and often chronic.

Clinical implications
Persistent stuttering is complex and can result in multifaceted psychological consequences (Bloodstein & Bernstein-Ratner, 2008). It is of importance for clinicians to consider life changing events and how these may impact on an individual's psychological wellbeing, as well as their stutter, in a more holistic way when developing treatment programs. We believe that our findings are also relevant to other stressful life events that a person who stutters may have to deal with in their lifetime.
The study findings indicate that migrants to Australia who stutter experienced a range of stressors that impacted on their ability to settle into their new country, and having a stutter had added to the complexity of the migration process. Both migration and stuttering can be considered stressful, which impacts on an individual's ability to communicate effectively, their sense-of-self, and their social identity. These challenges are particularly impactful in the areas of securing employment and socialisation, two significant areas of a new migrant's life.
Clinicians working with migrants who stutter need to be aware of the notion of acculturation and understand that it is dynamic, so that the individual's psychological distress can be understood in the context of what is happening to them and the changes in their identity (Bhugra, 2004). That is, the impact of migration-related stressors on stuttering and overall quality of life could change over time during different stages of migration.
It is important to appreciate and be sensitive of the personal factors an individual has that may impact on how they cope with migration and stuttering stress. A person shifting from one culture to another is likely to experience increased feelings of difference, as well as conflict within their self-identity. This potentially increases difficulty with managing the stress of migration and the stress of stuttering.
This study found that the perception of better acceptance of stuttering in Australian society, and the potential benefits gained from engaging in community support groups for people who stutter, are common facilitators to coping with stuttering. Therefore, clinicians are encouraged to consider resources and strategies that are available to them to support their clinical programs such as referring their clients to community support groups for stuttering, and to focus on the concept of self-acceptance in the person who stutters.

Limitations and further research
It is yet to be seen if the findings of the current study are also relevant to migrants who stutter when moving to countries other than Australia. There was a sample of only nine participants in this study, so more work is required to fully understand this topic. As this was a convenience sample, the participant characteristics specific to migration background could be gathered and investigated in more detail. Data regarding socioeconomic status at the time of migrating was not collected and is likely an important factor to consider in future studies. Also, we are unsure if participants considered themselves to be migrants at the time of the study. We expect that this is a highly individual and subjective interpretation and it would be interesting to see more investigation into migrant identity and its association to stuttering.
More information could be gathered around the circumstances and reasons as to why the migrants moved to Australia in the first place, to gain a better understanding of what factors impacted on their experiences, and how stuttering may or may not have impacted on such experiences. A migrant can be a refugee or an economic migrant, and this is likely to have implications for how one experiences migration (Bhugra et al., 2014). Push factors for migration are often related to stressful and traumatic experiences, and consequently, there is considerable interest in the investigation of refugees and their mental health (e.g., Gülşen, Knipscheer, & Kleber, 2010;Ryan, Kelly, & Kelly, 2009). Further research is recommended to investigate the impact of aspects such as trauma in refugee migration and settlement.
The process of migration could be another area of interest in future studies, to help elucidate experiences before, during, and after migration (settling and acculturation). The preliminary results of the current study suggested that participants experienced an increased level of stress during the initial stage of migration (soon after arrival), hence it is hypothesised that there are different factors impacting on the experiences for each of these migration periods. There could be future studies focussing more on post migration processes of acculturation, as described by Berry (1980). Acculturation depends on the distance between the two cultures and the willingness of an individual to change, and it is a dynamic process. It is linked to a range of areas including but not limited to language, religion, entertainment, food, shopping habits, individual cognitive styles, behavioural patterns, and attitudes (Roberto & Moleiro, 2016;Stevens, 2010).
By using a questionnaire such as the MIGSTR10 (Müller et al., 2012), it is possible to quantify the stress, stressors, and reactions to distressing events in the context of migration and settling, as well as to investigate how migration-related stressors are associated with other factors regarding cultural disparity, resilience, stuttering severity, and impact of quality of life. Overall, carefully designed studies may shed light into the process of migration and how it relates to stuttering, particularly if they are longitudinal in nature.
The nature of the sampling procedure also resulted in participants who were all engaged with external support for their stuttering. The fact that all participants were recruited from a community support group for people who stutter may have resulted in bias towards those who have 'success' stories. However, the reader is reminded that no participant in the study had scored mild impact scores on the OASES™, and that only one of the nine participants had reported no particular experiences of stress migrating to Australia. Even so, a future sample with migrants who stutter who had not engaged with a support group could help to broaden our understanding of the range of experiences of migrants who stutter.

Conclusions
This study is the first to provide a platform for migrants who stutter to tell their stories, in order to increase our understanding of their experiences. Migrants who stutter bring with them a background of individual experiences and factors, such as race, ethnicity and languages spoken, which impact on their ability to establish themselves in a new place of residence. Both the experiences of migration and of stuttering can be stressful and can impact sense of self, an individual's ability to achieve effective communication in order to connect with others, advancement in employment and the ability to fit in. Better recognition of the combined impact of migration and stuttering may facilitate understanding and the development of supportive responses to these challenges for migrants who stutter.

Funding
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.