The “Skinny” on Stuttering Therapy

Working with stuttering for the first time, it always seems to take a while to sort out what's what. I've tried to outline the process of therapy and the pitfalls students who have preceded you have encountered in this clinic (and learned from). Every student has found that it takes some time (and experience) for some of this to make sense..… but every student has gotten it. There are usually two things that complicate your work. First, a lot of the stuttering you will encounter is very subtle; at first you may not every notice it. Second, your client frequently tries to hide or disguise his or her stuttering and their feelings, making it even more difficult for you. Over time you will become skilled at knowing their stuttering and feelings better than they do and will be able to teach them about it.

You'll be spending a lot of time and effort with your client working on speech targets; modifying and changing the manner and habits with which your client speaks. But you'll find that the targets are only one step (albeit, a critical step) toward overcoming stuttering. They work to surmount the effects of the client's emotions and fear on the motor skills utilized for speaking and the perception of themselves as a speaker.

Fear plays a very confounding role in stuttering; and anxiety is fear's accomplice. Together they have rather disastrous effect on your client's speech. The fear is a normal reaction when we confront a danger. For the person who stutters, that “danger” is the negative consequences of their stuttering --- the “psychological” pain associated with embarrassment, shame, and injustice.

Recall that stuttering is defined as the “involuntary” interruption (repetition, prolongation, or blockage) of sound production while speaking. The interruptions are uncontrollable; the person who stutters feels he or she cannot help be stutter (it happens “to them”) – it's out of their control. From this perspective, they feel helpless and victimized by their stuttering.

Anxiety comes from the anticipation that something “bad” will happen. The person who stutters has learned that “When I speak I will stutter and be embarrassed and there's nothing I can do about it.” When in a situation that they will have to talk, they are usually very anxious about it (some more so than others). Anxiety erodes confidence and effects other compensatory behaviors. How does anxiety that you experience affect you?

When something repeatedly happens that embarrasses you, and you can't keep from doing it, it often leads to feelings about yourself – such as being inadequate, ashamed, or that something is wrong with you. Thus, stuttering becomes a part of the person and his or her personality.

You'll notice that your client will often react to speaking in ways which often increase the likelihood that he or she will stutter. Most clients speak too fast or force sounds out. These are reactions to the fear and anxiety which accompany stuttering and have become engrained into the way they habitually speak. Most of the time, the client is unaware of these reactions. Your attempts to slow their speaking rate will seem “unnatural” to them, even though it improves their fluency. “Selling” target use will be part of what makes your job difficult.

Another “miscue” made by many clinicians new to working with fluency disorders is counting the disfluencies the client experiences. Remember the objective for the client is to use his or her speech targets -- that's what you count or tally. We are trying to have the client substitute the new speech targets for his or her old habitual speaking patterns (you'll see that this is no easy task). Consequently we document the number of times they are able to use their targets. Theoretically, the speech targets are incompatible with stuttering; if they use targets they won't stutter. Secondly, stuttering is variable; sometimes clients are very fluent for no apparent reason. While everyone feels great that the client is fluent, they actually haven't learned anything. They didn't do anything (use targets) to be fluent. Consequently when their luck turns (and it ALWAYS does), they haven't gotten any better at implementing their targets to combat their disfluencies. Some have called this short-term fluency “fortuitous fluency”; but when luck runs out (usually when it's really important to be fluent, like in an interview) the client finds they haven't improved their ability to control their stuttering and be more fluent. The point of using speech targets is to enable the client to learn to use “controlled fluency” on demand. This empowers them, relieving them of being and feeling victimized by their stuttering. This is the fundamental part of therapy. The extra work of using targets to be fluent reduces the fear, anxiety, and emotions relating to speaking and lessens their effects, promoting more naturally fluent speech.

Once the client can demonstrate controlled fluency, the direction of therapy focuses on changing their feelings, attitudes, and perceptions of speaking – altering the client's perception of himself or herself as a speaker. This segment is similar to coaching the client to be a better public speaker and a more effective communicator. Making anxiety-related behavioral changes in adults is very difficult. Improvement usually comes in small increments. However, as you'll see, the impact of your work can alter the life of your client.

So, in summary, here are some “rules of thumb” to get you started:

• Learn your clients stuttering pattern – I will likely ask you to demonstrate (imitate) the way they stutter after a few week's experience working with them.
• Your interest should be in their target use, not their fluency. Fluency is a byproduct of target use. The more successful they are using targets, the more fluent they will become (on demand).
• Every client is an individual; there are no rules that apply to everyone who stutters.
• Get to know who your client is. Successful therapy is about treating the person, not the speech.
• This is very hard work; there will be times that both you and your client will be frustrated. There is only a need to be honest and forthright with your client if you expect them to respond to you in that way too.


	Stuttering Therapy Primer
	The “Skinny” on Stuttering Therapy Working with stuttering for the first time, it always seems to take a while to sort out what's what. I've tried to outline the process of therapy and the pitfalls students who have preceded you have encountered in this clinic (and learned from). Every student has found that it takes some time (and experience) for some of this to make sense..… but every student has gotten it. There are usually two things that complicate your work. First, a lot of the stuttering you will encounter is very subtle; at first you may not every notice it. Second, your client frequently tries to hide or disguise his or her stuttering and their feelings, making it even more difficult for you. Over time you will become skilled at knowing their stuttering and feelings better than they do and will be able to teach them about it. You'll be spending a lot of time and effort with your client working on speech targets; modifying and changing the manner and habits with which your client speaks. But you'll find that the targets are only one step (albeit, a critical step) toward overcoming stuttering. They work to surmount the effects of the client's emotions and fear on the motor skills utilized for speaking and the perception of themselves as a speaker. Fear plays a very confounding role in stuttering; and anxiety is fear's accomplice. Together they have rather disastrous effect on your client's speech. The fear is a normal reaction when we confront a danger. For the person who stutters, that “danger” is the negative consequences of their stuttering --- the “psychological” pain associated with embarrassment, shame, and injustice. Recall that stuttering is defined as the “involuntary” interruption (repetition, prolongation, or blockage) of sound production while speaking. The interruptions are uncontrollable; the person who stutters feels he or she cannot help be stutter (it happens “to them”) – it's out of their control. From this perspective, they feel helpless and victimized by their stuttering. Anxiety comes from the anticipation that something “bad” will happen. The person who stutters has learned that “When I speak I will stutter and be embarrassed and there's nothing I can do about it.” When in a situation that they will have to talk, they are usually very anxious about it (some more so than others). Anxiety erodes confidence and effects other compensatory behaviors. How does anxiety that you experience affect you? When something repeatedly happens that embarrasses you, and you can't keep from doing it, it often leads to feelings about yourself – such as being inadequate, ashamed, or that something is wrong with you. Thus, stuttering becomes a part of the person and his or her personality. You'll notice that your client will often react to speaking in ways which often increase the likelihood that he or she will stutter. Most clients speak too fast or force sounds out. These are reactions to the fear and anxiety which accompany stuttering and have become engrained into the way they habitually speak. Most of the time, the client is unaware of these reactions. Your attempts to slow their speaking rate will seem “unnatural” to them, even though it improves their fluency. “Selling” target use will be part of what makes your job difficult. Another “miscue” made by many clinicians new to working with fluency disorders is counting the disfluencies the client experiences. Remember the objective for the client is to use his or her speech targets -- that's what you count or tally. We are trying to have the client substitute the new speech targets for his or her old habitual speaking patterns (you'll see that this is no easy task). Consequently we document the number of times they are able to use their targets. Theoretically, the speech targets are incompatible with stuttering; if they use targets they won't stutter. Secondly, stuttering is variable; sometimes clients are very fluent for no apparent reason. While everyone feels great that the client is fluent, they actually haven't learned anything. They didn't do anything (use targets) to be fluent. Consequently when their luck turns (and it ALWAYS does), they haven't gotten any better at implementing their targets to combat their disfluencies. Some have called this short-term fluency “fortuitous fluency”; but when luck runs out (usually when it's really important to be fluent, like in an interview) the client finds they haven't improved their ability to control their stuttering and be more fluent. The point of using speech targets is to enable the client to learn to use “controlled fluency” on demand. This empowers them, relieving them of being and feeling victimized by their stuttering. This is the fundamental part of therapy. The extra work of using targets to be fluent reduces the fear, anxiety, and emotions relating to speaking and lessens their effects, promoting more naturally fluent speech. Once the client can demonstrate controlled fluency, the direction of therapy focuses on changing their feelings, attitudes, and perceptions of speaking – altering the client's perception of himself or herself as a speaker. This segment is similar to coaching the client to be a better public speaker and a more effective communicator. Making anxiety-related behavioral changes in adults is very difficult. Improvement usually comes in small increments. However, as you'll see, the impact of your work can alter the life of your client. So, in summary, here are some “rules of thumb” to get you started: • Learn your clients stuttering pattern – I will likely ask you to demonstrate (imitate) the way they stutter after a few week's experience working with them. • Your interest should be in their target use, not their fluency. Fluency is a byproduct of target use. The more successful they are using targets, the more fluent they will become (on demand). • Every client is an individual; there are no rules that apply to everyone who stutters. • Get to know who your client is. Successful therapy is about treating the person, not the speech. • This is very hard work; there will be times that both you and your client will be frustrated. There is only a need to be honest and forthright with your client if you expect them to respond to you in that way too. © Rentschler, 2005