To those “newbies” starting Stuttering Clinic, our first step is establishing an understanding of stuttering --- forming a philosophy of the disorder. This foundation will enable you to form a framework for your therapy, better respond to patient questions, and envision the next steps in your client's therapy. So let's begin with the “short course” in stuttering.

What Stuttering is About

Starkweather's (1987) explanation is a simple, yet elegant explanation of the disorder in his “demands/capacity” model. He says that people who stutter have a predisposition to stutter, for their speech to “breakdown”. So, the PWS has a weakness in their speech system that results in disrupted speech. About half of those who stutter have relatives who stutter or stuttered at one time. So we believe that the predisposition is likely hereditary in some who stutter. For the others, there may be “weaknesses” in the speaking process; motor coordination, muscular control, sentence formulation, word finding, auditory monitoring, or other functions that would serve to interrupt the flow of speech. Disfluencies result because the demands of speaking are greater than the speaker's capacity to maintain speech continuously.

Speech is a “social behavior”; it happens in an environment where others are present. Starkweather posits that when the speech system is stressed by factors present in the speaking environment (demands), speech disruption (stuttering) results. PWS report that their speech is “just fine” much of the time. But when stressed, like during a presentation, job interview, talking to the boss, or on the phone, the speech system breaks down at the weakest point. You will learn that each PWS has different stressors; but there are also many situations that commonly result in stuttering among PWS. When the stressors (demands) exceed the speaker's capacities to maintain continuous speech, disfluency results.

In young children, many things are developing simultaneously that can affect fluency – language development, muscular growth and control, coordination, motor control, cognitive skills, and on and on and on. These developmental components grow at different times, at different rates, and sometimes in bursts. When the growth of on area (say their cognitive skills) outpaces the growth of their speech/language skills, disfluency can be a result --- they simply don't have the words or know how to express these new discoveries; it can take a while for speech/language to catch up. Until it does, disfluencies can result. Perhaps that explains why children go through periods of fluency and disfluency, sometimes for several years.

At some point, usually before adolescence, PWS come to be aware and concerned that there is a difference in their speech – a difference that they cannot readily control or do anything about. The harder they try to control it, the more they struggle and the more overt their stuttering becomes. This leads to frustration, embarrassment (and other feelings), and the feeling of be a victim of their stuttering. PWS are quick to learn that they can't say words beginning to “t” or they can never get their own name out. At this point, stuttering becomes resilient and much harder to manage. At some point, the PWS internalizes their stuttering and begins to think of themselves as a “stutterer”, rather than a person who stutters; it becomes an integral part of who they are.

What Therapy is About for Chronic Stuttering

For adolescents and adults, therapy is comprised of three components – (1) learning to better manage their existing stuttering, (2) learning new, fluency enhancing speaking techniques, and (3) coping more effectively with the feelings and emotions that accompany stuttering. Each client who stutters has a unique history, stuttering pattern, and feelings and beliefs about their stuttering.

Your first (and continuing) job as the clinician is to learn everything specific to your individual client – what their symptoms are, what they've been through, when they stutter and with whom, when they are fluent, and what their environmental stressors are and how the react to them. This requires time and trust on the part of the patient. Just like making a new friendship -- we continue to learn more and more about the client each time you are with them. Thus, getting the client to tell his or her story is a part of the therapy; perhaps the most important part. You'll see that how they think and what they believe contributes to how they behave. When someone pulls a rubber snake out of a bag, you scream and jump, right? That's because you believe it is a real snake. Your behavior was a natural reaction to a “life threatening” situation. Now, imagine how different your reaction would be if you knew for certain the snake was just a toy when it was pulled out. What you believe determines how you react.

So, if you believe you always stutter on your name, what's going to happen? Your body will react because your mind is sending out danger signals (the danger being to one's ego… I'm going to stutter on my name and embarrass myself, just like the last time). What we often observe in the client preparing (in fear) to say his or her name, is an increased speaking rate or more muscular effort than necessary to articulate, or a gasp for breath before saying the feared word. That's the “tell” and clients are usually totally unaware that they do that.

Your client is learning ways to manage their stuttering (not struggle as much) and acquiring different ways of speaking that are more conducive to fluency. These are their speech “targets”. Targets include slower speaking rate for just about all clients, but also light articulatory contacts, breath management, gentle voice onset, and the like. You might think of targets as substituting a smoother manner of speaking for stuttering. Ninety percent of what we do is train the targets. The irony is that at the end of therapy, the client won't need the targets anymore. They are merely a bridge to overcome their feelings and beliefs about their stuttering. When you're confident that a rubber snake is coming out of the bag, you don't need to scream and run. When you no longer believe that you are a victim of your stuttering, that you are confident in your ability to manage fluency, there is no longer need to use targets.

The targets are a substitute behavior; empowering tools to become fluent. The brain no longer has need to send out the “distress signal” which prompts the body to do the things that results in stuttering.

The truth is that stuttering never goes away; it is chronic. The significant difference is that the client is empowered and no longer needs to be the victim. However, you'll quickly see the “idealism” in this philosophical perspective when you are face-to-face with your client. The “battle” is very real and the “front line” is target use. You won't see evidence of any steady learning curve or even movement one baby step at a time in a particular direction.

You will need to identify three messages which are most important for your client. You will need to use them consistently and persistently over the entire semester to make any progress. Stuttering therapy is a real challenge.

What Therapy is About for Childhood Stuttering

Therapy for children (who are not yet confirmed of chronic stutterers) is much different. The heart of our dual-pronged approach of therapy is to lessen demands and strengthen capacities. First we work to identify the stressors (demands) in the child's environment and work with parents to modify them. On the second front, we identify and “subsystems” that are functioning at lower levels and work to develop them. For example, if the child's articulation or oral motor skills are delayed we would likely work to improve them first or concurrently with work on stuttering. Often scaffolding the other systems will greatly reduce the stuttering.

At the same time we work on managing more fluent speech production, sometimes indirectly by modeling and environmental manipulations. Or directly, but requesting the child change his or her speech to make it sound less “bumpy”.

Parents are always an integral part of the therapy as they play a much more influential role because of their relationship to the child and the time exposure with him or her.

Like Those Students Before You.....

Most “first timers” feel as though they don't know enough about stuttering or therapy, and their client knows way more than they do. Well most clients know more about their stuttering than I do, that's why we talk a lot about their stuttering as a part of therapy…. so, maybe there's some normalacy in your feeling a lack of knowledge in stuttering? So what's your role? Roger Federer, arguably the world's best tennis player, has a coach. Playing tennis, Federer could likely beat his coach playing left-handed. So what use is the coach? Well, the coach can see things from an entirely different vantage point than Federer, and can tell him what he's doing wrong and what he needs to do differently to beat his opponent. When you are “in action” you miss half of what's going on. Did you ever watch a video of yourself giving a class presentation? It can be “very informative”. So too for your client --- he or she needs a coach – and you're it. I'll play the part of the coach's coach, and together we're a team.

We have an entire semester to work together so that both you and the client come away having progressed. Ask questions – there's not a limit! Tell me what you don't know – I can tell you. Remember that knowing you don't know something is a step above not knowing you don't know something! There are no penalties for asking questions or not knowing something at this point in your career. But clients are penalized for having a clinician who's walking in the dark and afraid to ask where the light switch is. Remember, this isn't only about you; there's someone across the table needing your help.