Holistic Approach to Stuttering Using Rational Emotive Behavior Therapy (Heather Grossman, Gunars Neiders)

heatherAbout the authors:  Heather L. Grossman, PhD, CCC-SLP, BCS-F has worked with children and adults who stutter for over 25 years and was among the first select group of speech-language pathologists to receive board recognition as a specialist in the treatment of fluency disorders from ASHA. She has been the Director of the American Institute for Stuttering (AIS) in NYC since 2011. Dr. Grossman is extremely active in the stuttering self-help community. She is a frequent presenter at conferences of the National Stuttering Association and FRIENDS – the National Association of Young People who Stutter as well as national and international professional conferences. Before joining AIS, she was the speech services coordinator at Hofstra University and an adjunct professor at Long Island University, Mercy College, and Queens College. She received her doctorate degree in 2008 at the University of Louisiana at Lafayette where she researched aspects of the phenomenon of voluntary stuttering.
gunarsAbout the authors: Gunars K. Neiders, Ph.D. Elec. Eng., Psy. D. He is the author of the dissertation entitled “Theoretical Development of a Proposed Rational Emotive Behavior Therapy Based Model to Treat Persons with Chronic Perseverative Stuttering Syndrome” and book “From Stuttering to Fluency: Manage Your Emotions and Live More Fully”. His experience as a person who stutters, a licensed psychologist in private practice in Washington State, USA, and stuttering coach over Skype, resulted in the paper “Rational Emotive Behavior Therapy of Stuttering via Skype: Case Series Studies” presented at the International Fluency Association 8th World Congress in Lisbon, Portugal, July 6-8, 2015. Dr. Neiders also works part time training Psychology Doctorate students. He is currently writing a workbook to document the step by step application of REBT to stuttering therapy.

What REBT Teaches

Rational Emotive Behavior Therapy (REBT), founded by Albert Ellis in the 1950’s, is considered the Granddaddy of Cognitive Behavioral Approaches. It is a form of psychotherapy and a philosophy of living that can be very effectively applied to stuttering treatment. It is an extremely helpful adjunct to other therapies, including avoidance reduction and stuttering modification approaches.

REBT is based on the premise that we do not become upset directly because of the events that happen to us. Rather, the beliefs we hold about these events cause us to become depressed, anxious, enraged, etc. If, for example, you feel someone is laughing with you, you will likely have a very different response than if you perceive them as laughing at you. The idea that our beliefs upset us was first articulated by Epictetus around 2,000 years ago: “Men are disturbed not by events, but by the views which they take of them.”

REBT helps people who stutter (PWS) work to identify, dispute, and come to modify the self-defeating, unhelpful core beliefs they have about their speech and stuttering. It provides an extremely powerful way of improving one’s emotional responses as well as physical aspects of stuttering. Rather than over-hauling the entirety of speech, REBT work modifies the intrusive thoughts that disrupt speech in the first place. The goal of this work is to achieve free-flowing speech.

A person with free-flowing speech:

  • Communicates effectively. He says what he wants to say, where and when he wants to say it, with and without stuttering.
  • Is open to self-disclose stuttering, to stutter openly, and talk about it with others, both casually and seriously.
  • Recognizes that all people have breaks in their fluency and accepting that being perfectionistic about fluency is unhelpful.
  • Stutters with varying frequency and tension but always with self-dignity and confidence.
  • Recognizes that while he may prefer fluency, he does not demand it or put himself down for stuttering “too much.”
  • Engages in minimal avoidance behaviors or use of tricks/crutches to minimize/push through moments of stuttering. When he reverts to these behaviors, he is self-aware and reacts without self-downing or having shame about shame!

REBT is a semantic therapy. This means that the words we use are critical, since they affect how we feel, think, and act. It is of the utmost importance that, following the example of General Semantics, during both self-talk and talk to other people, we use words wisely, both with respect to their actual meaning and with respect to the connotation that might have unintended consequences.

Core Beliefs that hinder Free Flowing Speech

We generally make ourselves miserable by holding onto a set of inflexible beliefs about how we, how others, and how the world “should” and “must” be. These are:

  1. I must do well and win the approval of others for my performances or else I am no good.
  2. Other people must treat me considerately, fairly and kindly, and just as I want them to treat me.
  3. I must get what I want, when I want it; and I must not get what I don’t want.

The first belief often leads to anxiety, depression, shame, and guilt. The second belief often leads to rage, passive-aggression and acts of violence. The third belief often leads to self-pity and procrastination. It is the demanding nature of the beliefs that causes the problem.

In situations where PWS are not worried about possible negative consequences of stuttering and are not telling themselves they “should be fluent,” they usually find their speech flows more freely. The ultimate expression of this freedom comes about when the individual is speaking aloud when alone. You will note that at these times, the PWS is not using an external “tool” or “technique” to speak fluently. Rather, he/she is simply not engaging in negative self-talk or evaluative thoughts that serve as the source of extreme negative emotions, struggled speech, and self-defeating avoidance behaviors.

On the other hand, in situations where the PWS experiences strong negative reactions related to stuttering (for example, worrying that one will be laughed at in a situation where the listener appears judgmental) the following occurs:

  • The belief “I should not stutter here” activates increased emotional activity
  • There is an increase in stuttering frequency and severity (duration, struggle, tension)
  • The individual attempts to avoid stuttering by pushing through blocks, engaging in secondary/accessory behaviors such as blinking of eyes and snapping of fingers and

and/or other self-defeating avoidance behaviors

The look of the judgmental listener does not directly cause this negative chain of thought, unhealthy over-emoting, and unhelpful behavior.  Rather, unhelpful core beliefs that perpetuate that stuttering is bad and something that should be hidden are the cause of unhealthy over-emoting and the forced, struggled speech.

We can further identify five categories of emotional “hot-links” as they apply to stuttering that hinder free-flowing speech:

  1. Condemnation & Damnation of Self or Others. This is a belief that if a PWS does not live up to his/her expectations that he/she overcomes stuttering he/she should be damned and punished.
  2. “I-can’t-stand-it”-itis. This is the devout and misdirected belief that a PWS can’t stand the discomfort and frustration of a given situation.
  3. Awfulizing. When a PWS exaggerates the degree of badness of stuttering or spends too much time dwelling on some unfortunate event, he/she is said to be awfulizing.
  4. I’m Worthless. This arises from the quaint belief PWSs should be rated and categorized as to their worth using stuttering as the determining characteristic. Your stuttering does not make you worthless just as fluency does not make an individual worthwhile.
  5. Always & Never. This belief is frequently a pessimistic conclusion based on insufficient data. What sense does it make to say, “So far I have not been able to recover from stuttering, therefore I will never be able to do it.”

The real work of therapy is achieved by disputing and doing action-based exercises to counter the unhelpful thoughts and self-talk. Each belief is classified as irrational/unhelpful if all the following questions are answered in negative. For each inflexible demand or unhelpful belief, we explore: 1) where is the evidence? 2) does it logically follow from real-world observations? and 3) does it help the individual achieve his/her goals? If a belief is found to be irrational/unhelpful, these same questions can be used forcefully to convince oneself that the belief is not sound.

For example, “Why must I win everyone’s approval?” Upon exploration we realize that while it is fine to prefer being approved of by others, there is no reason why we absolutely must have this approval.

Learning to generate disputes for your own unhelpful core beliefs takes a great deal of practice, passionate questioning, repetition and consistency. We encourage clients to journal thoroughly as they go through this process.

You can live life fully with stuttering

REBT provides the solution to self-downing: unconditional self-acceptance, with or without stuttering. You don’t need to change a single thing except your attitude. Self-acceptance is available to you no matter what, even when you behave foolishly, and no matter how severely you stutter. You simply choose to accept yourself and nothing else is required.

Unconditional self-acceptance is a process where you actively acknowledge without judgment the following:

  1. I am a fallible human being; I have my good points and my bad points
  2. There is no reason why I must not have flaws
  3. Despite my good points and my bad points, I am no more worthy and no less worthy than any other human being.

Acting on your positive self-talk will help you achieve self-respect and dignity

If you want respect, it sure helps you if you believe in yourself. You cannot expect another person to respect you if you do not treat yourself with respect. If you feel you are not being treated with dignity, you need to be willing to stand up for yourself.

Listeners will take their cues about how to treat you from you. Consider how you self-disclose your stuttering. Do not apologize or look defeated. Instead, stutter with confidence, maintaining normal eye contact and social contact with your listener. Request what you would like from your listener (eg. “Hello, I stutter, please be patient as it will take me some extra time to speak.”)

Try to be mindful of your self-talk about stuttering:

Rather than: Resenting that you HAVE to self-disclose, feeling it is something you are giving the other person,

Try: Recalling that self-disclosure allows you to stutter freely, and feel PROUD of how you disclose with confidence, even though it’s not always easy

Rather than: Condemning yourself for stuttering with struggle and tension,

Try: Giving yourself credit for saying what you want to say, especially since it may result in more stuttering. Remind yourself that you are resilient.

Rather than: Beating yourself up for avoiding a word or situation,

Try: Using the fact that you now have the awareness that these behaviors are NOT helpful as a positive reminder of how far you have come.

Rather than: Feeling bad because you let yourself get embarrassed that you stuttered,

Try: Having pride that you pushed through discomfort. You made eye contact even though you were uncomfortable stuttering.

 

Some activities to complement work on shifting unhelpful core-beliefs:

Sometimes the best self-talk and emotional state does not alone change the stubborn habits of forcing and struggling with the speech. There is after all, a learned motor component to stuttering akin to a habit. There are many ways to construct activities to further lessen struggled speech. We will introduce a couple samples here as they apply to REBT:

Hanging onto a stuttered word

What are you trying to accomplish?

You intend to show your whole brain that it is possible to not feel the urgency to get out of a block using a crutch or other avoidance. You are desensitizing yourself to moments of real stuttering so that you can become less negatively reactive to tense moments of stuttering. You are working on being fully present while you are stuttering. You are learning that you have agency regarding your stuttering.
What beliefs do you acquire?

  1. “ I can learn to stay calm even when I stutter.”
  2. “ I can stand disfluency no matter how severe and how long it is.”
  3. “There is no reason why I cannot fully experience and explore my relationship with my stutter.”
  4. “While it is not comfortable to stutter openly, especially in front of others, I am entitled to do so.”

How is it to be done?

Mindfully “catch” yourself in a moment of stuttering. Experiment with “holding” onto the position of your mouth and audibly extending the stuttered sound. Your intention is to break your habit of postponing, avoiding, or pushing through moments of stuttering and to be able to stay present and mindful when stuttering. It does not have to be tension-free or sound pretty. Hold the stutter a full 3 seconds longer than you otherwise would. Calmly continue speaking.

See demonstration by GN on YouTube at https://youtu.be/e-cC3WsBrTM

Begin by practicing for about 15 minutes while alone in the mirror. This is a faked version that in appearance is the same as the real thing. Then find a situation where real disfluencies come up so you can do it for real in front of your stutter buddy or therapist. Finally, do it in front of a friend or stranger or over the phone with the friend or stranger. Use REBT to convince yourself that nothing horrible, terrible, and awful happens.

Cancellations

What are you trying to accomplish?

You are trying to break your habitual pattern of stuttering with struggle and avoidance. Ultimately, cancellations train you to stutter in a more confident, forward-moving, non-avoidant manner. Since during moments of stuttering, it is difficult to not push through or use a physical secondary or other crutch, it is very helpful to modify these characteristics after they occur. You are building a new stuttering muscle memory. You are doing behavioral work to support the re-shifting of core beliefs that help you achieve free flowing speech.
What beliefs do you acquire?

  1. “Even in the middle of a real-life conversation, I can practice stuttering openly.”
  2. “I am allowed to take some extra time for my speech. There is no need to rush.”
  3. “If these listeners are confused by what I’m doing, I can explain what I’m doing or I can just go about my business without worry!”
  4. “Even though it is natural for my body to revert to avoidant stuttering, I still have the power to make change.”

How is it to be done?

See the following YouTube video for a demonstration.

First practice alone. Simulate as best as you can what happens when you really have a tense stutter. Complete the entire word, stuttering through to the end. Then, take a very mindful pause of at least 2-3 seconds to contemplate your tense, avoidant stuttering behavior. Then, repeat the word, being sure to stutter the word voluntarily using free flowing bounces or another form of forward-moving intentional stuttering. Do not say the word fluently as this reinforces the idea that fluency is the direct goal of your work.

After practicing alone, find a situation where you stutter with a stutter buddy or therapist. Finally, try doing cancellations in front of a friend or stranger or over the phone. Again, you may find it difficult to successfully “cancel” each moment of tense stuttering. Notice your body and thoughts at these times; these are opportunities for growth.

Summary:

REBT, a powerful, evidence-based therapy, can help PWS identify, dispute, and come to change the self-defeating, unhelpful core beliefs they have about their speech and stuttering. This change results in improvements in both emotional and physical aspects of stuttering. For PWS, the tools of REBT not only increase the frequency of free- flowing speech, but also facilitate the achievement of self-acceptance, self-respect, and dignified treatment by others in work and school situations.

For further reference about REBT:

Clark (2008) SOS Help for Emotions: Managing Anxiety, Anger & Depression

Neiders and Ross (2013) From Stuttering to Fluency: How to Manage Your Emotions and Live More Fully.

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Comments

Holistic Approach to Stuttering Using Rational Emotive Behavior Therapy (Heather Grossman, Gunars Neiders) — 45 Comments

  1. You can get to the video clips by googling:
    YouTube Neidersg Hanging on to a
    YouTube Neidersg Cancellation 02

  2. Hello Heather and Gunars. Thank you for this valuable paper; I hope and expect that it will be of tremendous benefit to PWS and to clinicians.

    Some questions, if I may:
    1) Is this holistic approach used at AIS?
    2) Is this approach used in conjunction with ACT philosophies, and, if so, how?

    Thanks so much.
    Hanan

    • Hello Hanan
      We do use this approach at AIS. While many of the concepts of ACT are consistent with REBT, we really do not reference ACT as a matter of course. We do incorporate many of the ideas and exercises from Avoidance Reduction Methodologies, and find REBT really helps people make progress changing their avoidance behaviors by changing their underlying thoughts that precipitate avoidances in the first place. We also greatly emphasize desensitization, mindfulness practices, and developing skills for increasing overall communicative effectiveness. Again, we find REBT helps people increase their readiness and ability to complete these challenges.

  3. Hi Heather and Gunars — thank you for the accessible and informative article! As a parent advocate, it’s important to me that parents understand what you say about it being “the beliefs we hold about these events, not the events themselves” that impact the severity of the impact of stuttering. It gives us something far safer to focus on than fixing the speech. I believe the goal of REBT goes beyond achieving free-flowing speech to living a happier life! Your point about negative reactions to judgmental listeners is key. My concern is when a young child is involved in speech therapy that focuses on fixing the stuttering — they are surrounded by judgmental listeners – and I cringe at the layers of anxiety that can build up. Speech therapists, especially for young children, should focus on keeping kids talking by being the best ear that kid has – opening up the opportunity for the SLP to hear about the beliefs that are developing in that child’s mind, and being able to address negative beliefs that may be forming — and including parents and teachers in the mix. Thanks for your guidance! Excellent!

    • Hi Dori!

      You are right that the foundation of REBT, whether applied to stuttering or in any other area of human behavior, is to above all influence the client to understand that the goal of living is to live life to the fullest and not to prove to anyone, including ourselves, that we are either good, or fluent, or able to achieve free-flowing speech. These ideas really do translate nicely to work with children.
      I find that even very young children come to therapy already having constructed that stuttering is “bad” and that they are being “good” when they do something that prevents a stutter.

      When I ask children to tell me what bothers them most about stuttering, the answer is usually related to listener reactions and the chance that they might be teased or laughed at if they stutter. A helpful area of dispute in REBT involves learning that while we WANT people to approve of us and treat us a certain way, it really doesn’t matter all that much what they think or do, and we that we can’t let others and their judgments stop us from getting out there and living. It’s what WE think that matters.

      We help children learn that ALL people have their strengths and flaws and that they make us uniquely human and amazing. We emphasize that the most important thing about communication is to use it interact with others and to get things done- saying exactly what you want to say- stutter or not. As listeners, we send that message by reinforcing content, listening actively, and interacting genuinely, not by reinforcing fluent speech.

      Thank you for your comments!

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  5. Hello!,

    Your explanation on the necessity of modifying the negative perceptions which many-times coincide with stuttering is masterfully framed.

    However, I wanted to ask your thoughts on whether REBT could harmonize with other therapeutic approaches, such as fluency shaping. While REBT is very much focused on mindfulness and unconditional self-acceptance, Fluency Shaping methodologies focus more on simply being fluent; I believe both these methodologies to have their own distinct benefits and drawbacks.

    So my question is, would it be consistent with the REBT framework to work on being fluent, while simultaneously maintaining healthy core beliefs–or are these two entities mutually exclusive?

    Thanks!

    • REBT does harmonize very well with avoidance reduction and other approaches that emphasize unconditional self-acceptance and stuttering openly. In my opinion, while working on fluency shaping, one’s mind tends to score the successes as times of fluency and failure as moments of stuttering. This creates a situation of contradictory intention- part of you is working to be totally non-judgmental of moments of stuttering, while you tend to sub-consciously be praising yourself for averting stuttering. I have seen way too many times how the same fluency strategy that “works” in practice becomes a new source of secondary tension and a sense of anticipatory anxiety when that person tries to use that “tool” in a real-life situation where they really want to be fluent.

      However, for those who have truly overcome the shackles of demanding that they be perfectly fluent, and no longer concern themselves with the reactions of others to their stuttering, the use of a physical strategy to speak more fluently can be a further aspect of their empowerment.

      And in an interesting twist: For some, playing around with different stuttering modification and fluency enhancing strategies provides a sense of agency- providing the real-world evidence that change is possible and firming up the knowledge that there are options when stuttering. Consistent with REBT, with these new-found core beliefs, they have a reduction in negative emotion to the point where they don’t need to “use” any outside strategy to speak freely.

  6. Hi there! I am a graduate student in speech therapy and currently taking a class in stuttering. I enjoyed reading this article- I am wondering if you would mind answering a few questions for me. I would love to hear your thoughts!
    1) Do PWS often hesitate to talk about the emotions behind their stutter?
    2) Is there a process that PWS often follow when beginning this program?
    3) Do different emotions arise during different times of therapy (more complex emotions later into therapy)?
    4) How many people do you see make significant improvements to their physical stutter using this therapy approach?

    • Thank you for reading and commenting on our paper. You pose some interesting questions. My answers are based on years of evolving and practicing REBTS.
      1) “Talking about emotions” is a skill. As the client becomes more aware of his emotional state, he also evolves the skill of expressing the emotional state. I attribute the hesitancy in talking about his emotional state at the beginning due to not being skillful at analyzing and expressing emotions. Have fun observing emotional change that is attributable to progress in therapy.
      2) The process of therapy was designed to go guide the client through the following early steps of therapy:
      a. Through facing reality and using REBT skills, the client toughens oneself and stops unnecessarily dramatizing the downside of stuttering. He achieves a state where he can have a ball on this earth whether one stutters or not.
      b. The client learns to accept himself unconditionally with or without stuttering.
      c. He discards most of his avoidances.
      d. Seeing that he is tough enough he experiments with deliberate (voluntary) stuttering and lets his conscious and subconscious brain absorb the data that he can stand stuttering.
      …you can get the rest of the process steps from the paper “Rational Emotive Behavior Therapy (REBT) Based Preferred Stuttering Recovery Process” from last year’s (2015) ISAD conference.
      3) See 1) above
      4) I have found out that just as soon as a client can truly acquire the REBT skills, the frequency and severity of physical aspects of stuttering improves.

  7. REBT seems to directly address Dr. Sheenan’s Iceberg analogy on stuttering. The visible tip of the iceberg represents the overt or seen aspects of stuttering, i.e. the stuttering itself. The invisible covert or hidden aspects represent the emotional and psychological aspects of stuttering. Traditional fluency shaping seems to only address the tip of the iceberg, has low long-term success rates, and may be reinforcing negative self perceptions. REBT seems to allow the PWS to gain control of not only their thoughts and beliefs, but that actual stuttering itself. By cancellations and hanging onto a stuttered word it gives power back to the PWS.

  8. Dr’s Grossman and Neiders

    Thank you for the wonderful paper. The REBT is something I am learning and have embraced. I agree that what we need to be focusing more on attitudes and what we say to ourselves rather than the event itself. In my opinion, attitudes/self-acceptance is the starting point to any kind of stuttering therapy.

  9. Hi Dr. Grossman and Dr. Neiders,

    I am a first year graduate student in speech pathology and I have had limited experience with fluency, thus far. I have a question regarding how you implement RBET therapy. Is it beneficial to implement this approach before any other approaches are tried to help a client change their negative beliefs and/or behaviours about their stutter? Or would it be more beneficial to incorporate it in conjunction with another therapeutic approach, such as fluency shaping?

    Thank you for the wonderful paper, I thoroughly enjoyed it.

    Gabrielle

    • Thank you for reading and commenting on our paper. You pose some interesting questions. My answers are based on years of evolving and practicing REBTS.
      1) “Talking about emotions” is a skill. As the client becomes more aware of his emotional state, he also evolves the skill of expressing the emotional state. I attribute the hesitancy in talking about his emotional state at the beginning due to not being skillful at analyzing and expressing emotions. Have fun observing emotional change that is attributable to progress in therapy.
      2) The process of therapy was designed to go guide the client through the following early steps of therapy:
      a. Through facing reality and using REBT skills, the client toughens oneself and stops unnecessarily dramatizing the downside of stuttering. He achieves a state where he can have a ball on this earth whether one stutters or not.
      b. The client learns to accept himself unconditionally with or without stuttering.
      c. He discards most of his avoidances.
      d. Seeing that he is tough enough he experiments with deliberate (voluntary) stuttering and lets his conscious and subconscious brain absorb the data that he can stand stuttering.
      …you can get the rest of the process steps from the paper “Rational Emotive Behavior Therapy (REBT) Based Preferred Stuttering Recovery Process” from last year’s (2015) ISAD conference.
      3) See 1) above
      4) I have found out that just as soon as a client can truly acquire the REBT skills, the frequency and severity of physical aspects of stuttering improves.

  10. Hi Heather and Gunars,

    I very much enjoyed your paper. Thank you. Two questions please. Do you believe that all stuttering is a result of negative beliefs, unrealistic expectations etc. or do you believe Habit may play a role in some cases? Secondly, awareness of Safety behaviour formation seems to be becoming a key component of modern therapy. Could you comment?

    Kind regards,

    Mark Irwin

    • We do believe that habit formation does play a big role.. by reacting to moments of stuttering the same way over time, the reactions, including physical secondary movements, do seem to become rather habitual. In such cases, REBT will help reduce the thoughts & emotions that trigger the habit, and working on stuttering more easily and confident and practicing some voluntary stuttering and cancellations can help reduce that habitual muscle memory.

      I also think safety behavior formation is a huge factor in stuttering. I tend to equate safety behaviors with avoidance behaviors ( examples: leaving the room when it it time for introductions, using text vs. phone, having someone else place a food order, etc) REBT harmonizes so well with avoidance reduction while recognizing that we all have to “choose our battles.” In my opinion, if a safety behavior is only occasional and not self-defeating, it can be just fine to have some self-acceptance without putting yourself down for “making it easier” So for example, let’s say someone chooses on a certain day to e-mail rather than call in an order, all the while cognizant that a part of this choice is to avoid stuttering but also that he typically make calls such as this.. No reason to put himself down!
      Thank you for the questions

  11. Hi Heather and Gunars,

    I enjoyed reading this article and had some questions. Do you find implementing this therapy more difficult for a certain age group? I can imagine that as children get older they become more aware of other’s perceptions of them, which could make this therapy harder to be effective?
    Thanks!
    Kathleen

    • Kathleen,
      Thank you for submitting your questions. Unfortunately, I have not had much direct experience with children and teenagers. The experience I have had is that teenage years are very difficult because of the teenage focus on acquiring peer acceptance.
      Gunars

  12. Hello,

    I am in my second year of Grad school and am currently enrolled in a Fluency course. I was wondering if you have had any difficulty with clients being able to open up and connect to their emotional struggles? I know this is an area in my life that is difficult, so I was wondering what approaches you have used to tap into the negative emotions the PWS may be feeling?

    Thank you for posting, I find this type of therapeutic approach extremely helpful and look forward to implementing it in the future!

    Rachel

    • Rachel,
      I have found that all work involving emotions is both intricate and requires a good therapeutic alliance. Fortunately, REBT literature provides a good road map how to do this. For example, you could check out my website for further suggestions.
      Gunars

  13. Hello,

    I am in my second year of graduate school and am currently taking an advanced fluency course. I found your paper to be very informational! After reading, I had a few questions I was hoping you could answer.
    1. Is REBT something that can be used as a stand alone therapy approach? If not, what approach do you typically pair it with?
    2. Is there an age group that this approach is most appropriate to implement with?
    3. How does one begin to use this approach?

    Thank you for your time!
    -Katie

    • Dear Katie,
      1) Since I am convinced that all people, whether they stutter or not, construct in their heads an image of reality that is unique to them, for the best results we as therapists have to tailor our therapy to each individual client. The way I do this is to start with REBT and, if that is not enough, add in elements from Stuttering Modification. Sometimes the client, having undergone Fluency Shaping practically insists that we fold in some of the aspects of that approach also. As long as the client follows the basic tenets of REBT as explained in our paper, I see nothing wrong with this approach.
      So what basic things do I watch for as danger signs? First, when the client starts to chase the fluency goddess and second, when the client subscribes to conditional self-esteem, instead of unconditional self-acceptance. Of course, the easiest way to catch a wayward thinker is to monitor his or her self-talk. When shoulds and musts appear, it is time to further examine them. Some sentences that cause great deal of backsliding are: “I must do well and impress all the people with whom I interact.” “I should not stutter!” and all the other things we mention in our paper.
      2)I have found out that just as soon as a client can learn logic and scientific thinking he or she is ready to pursue REBT based therapy.
      3) The best way, perhaps the only way, to begin to use this approach is to learn REBT from one of our references. Then start using in your own life for various challenges that life puts up. Once you can apply REBT to your own life, to life problems in general, applying to stuttering and other problems will come naturally.
      Good luck,
      Gunars

  14. Hi Dr. Grossman and Dr. Neiders,

    Thank you for sharing your information about REBT therapy techniques. As a future clinician, I think it is very important to be aware of all of the side effects that coincide with the physical aspects of stuttering. I believe that by addressing the emotional behaviors during early therapy sessions is key! I am curious to know by what age is too early to begin REBT? If the child does not have negative emotions towards stuttering, should we address the behavioral techniques into therapy so soon?

    Thank you again,
    Amber

    • Amber,
      I highly recommend Ann Vernon’s book Thinking, Feeling, Behaving: An Emotional Education Curriculum for Children grades 1-6
      Her book shows how to introduce discussion even in first and second grades can lead to foundations that can serve the child throughout his or her lifetime. The following are just a miniscule part of topics/objectives that can be addressed just as soon as a child enters school(these are taken from self-acceptance activities in her book).
      Here is just a sampler of objectives:
      1) To recognize that there is something unique about everyone.
      2) Learn that people have both strengths and weaknesses.
      3) To recognize that people grow and change.
      4) to learn that making mistakes doesn’t make people bad or stupoid.
      5) To learn how to accept yourself for who you are.
      Ann Vernon is ingenious in that she uses stories and parables followed by questions; she uses people hunt exercise-finding a schoolmate with freckles, missing tooth, birthday in a certain month etc.
      Does this mean that we cannot start teaching self-acceptance before a child enters school. Hardly. When a parent or a caretaker devotes undivided attention to a child balanced by a turn taking situation, the child learns both that he has value as do others.
      Anyone working with children should check this book out as well as the companion model aimed at students in Middle and High Schools.
      In summary, one does not have to be using abstract techniques to teach rational attitudes toward life.

      • Thank you for this additional information. I am also a graduate student and am working with a kindergartener who stutters. This book by Ann Veronon sounds like an excellent source for not only SLPs but also for teachers and parents. I agree that each of us has created our own reality in our heads. The idea of shaping children’s ideas so that they develop with self acceptance is wonderful. Thank you again.

        Kliss

  15. Hello Dr. Grossman and Dr. Neiders,
    I am a first year grad student in speech language pathology, and was excited to have found your article! Since taking my undergrad fluency class, I have been very interested in using REBT with fluency clients. Do you believe that REBT is within the counseling scope of practice of an SLP, or do you think we should refer clients to a psychologist/psychiatrist? Thank you for the insightful article.
    Lydia

    • Lydia
      REBT is well within the scope of practice of an SLP. Learning REBT from a book like Clark’s and searching out some workshops on REBT, you can gain counseling skills that would help you not only with fluency clients (stuttering and cluttering), but also with all of the other clients. We have found that applying the REBT principles have also improved our own functioning and is helping to live our lives to the fullest.
      Gunars & Heather

  16. Hello Dr. Grossman and Dr. Neiders,
    Thank for for the great article. Like many, I am a graduate student in speech language pathology. This article made me take a step back and revisit why I wanted to become an SLP in the first place- to help people become an effective and confident communicator (as opposed to a normally fluent speaker). A a future SLP, to help a person using REBT as a basis, when I am working with them on cancellations or mindful stuttering events, should I take a few minutes to talk about their experience after each event?

    • Hi,
      You do have good instincts! Of course, the more aware the clients become of their emotions and self-talk, of their triumphs and floundering, of their rational and irrational attitudes, the easier it is for them to focus on helpful and healthy thoughts, emotions, and behaviors.
      One caveat! See if you can draw the clients out. Encourage them via Socratic questioning delve into their particular cognition/emotion connectivity.
      Good luck,
      Gunars

  17. We received several questions related to implementing REBT with children. The procedures we describe such as becoming aware of core beliefs that contribute to negative emotions are not intended to be used with young children. However, many of the over-riding philosophies and discussions are perfectly adaptable and very helpful. For example, we can help children NOT develop core cognitions such as “People who stutter can’t have jobs like being an actor” by introducing them to PWS who are actors. We can help reduce the potential sting of teasing by having them self-disclose and educate classmates in school, and work on building their overall confidence, resilience and self-acceptance- all very consistent with REBT.

    • And if you have time, check out the books by Ann Vernon of how to design activities, readings, and discussions. The books are entitled “Thinking, Feeling, Behaving: Emotional Education Curriculum for children
      Gunars

  18. Hello Dr. Grossman and Dr. Neiders,
    Thank you for providing some insight into the personal emotional landscape a person who stutters might have. It occurs to me that REBT is a useful tool for everyone. If a person who stutters were to use this approach they would be gifted with the opportunity to heal many aspects of their lives. As a normally fluent person, I have other challenges that feed my negative self-talk. Being present is something we all owe ourselves. I would be curious about if this is something you would use in conjunction with any other therapy or when you might introduce it to a new client.

    • Hi Mary,
      If I understood your question correctly, you are asking if REBT can be used in conjunction with other therapy to provide a “shining path” to living life to its fullest. Personally I have found out that the more I immerse myself and my clients in REBT philosophy and problem resolution techniques the more progress I am making in creating my life to my liking. The only danger I can see is that some “other therapies” may have contraindicated goals such as “I must prove myself to be a worthy individual” (instead of just accepting yourself and learning to maximize your talants and minimize your shortcomings. And never, never subscribe to chasing the goddess of perfect fluency.
      If this is not what you were asking, then could you, please, restate the question?
      Respectfully,
      Gunars

  19. I think this approach to treatment is extremely useful. Often, PWS have extremely strong beliefs about themselves that increases their anxiety and anger about stuttering. while cognitive therapy alone may help with the beliefs, by combining it with behavioral interventions it really can alter the behaviors related to the negative thoughts. I am wondering if their are differences on the effectiveness of REBT with children who stuttered early, vs. those who acquired stuttering as a result of trauma?

    • Kayla,
      I have not heard of any study that answers your question. My experience with using REBT with acquired stuttering is that it is extremely helpful with correcting low frustration tolerance, which in turn lets the clients work more effectively and efficiently on their assigned corrective work.
      Good luck,
      Gunars

  20. Dear Dr Grossman and Dr Neiders,
    I am a Speech and Language Therapy student from the UK and am currently beginning to learn about dysfluency. I really enjoyed reading your article on REBT, it is very informative and great information for me to take forward with me on my course.
    Charlotte

  21. Hello Dr. Grossman and Dr. Neiders,

    I am a second year graduate student and have a great interest in the field of fluency. I believe this therapy approach is very beneficial to the underlying emotions that many PWS experience. After reading your article, I was wondering what typically has been found to be the most effective technique to make PWS more comfortable and open with their stuttering?

    Thank you for this educational article,
    Christina

    • Christina,
      I am a constructivist by persuasion. This means that I believe we construct our image of reality in a way that both enhances and hinders our functioning. What I have found to be the most valuable is the conviction of the client that REBT works on all types of emotional problems. Once a client as solved something like an eating problem, the stuttering problem resolutions becomes so much easier. In summary, I teach my clients to apply REBT principles in everyday living as well as in recovery from stuttering.
      Respectfully,
      Gunars

  22. Hello Dr.’s Grossman and Neiders!
    Your article provided great insight for me into the effective ideology behind Cognitive Behavior Therapy with regard to Stuttering and Acceptance Therapy. As a current Speech-Language Pathology graduate student and a former Behavior Tutor for children with Autism, I have some personal experience with using CBT to help my former students through pragmatic language skill difficulties, and I am glad to see that your research and clinical practice has afforded you the time to cultivate intervention centered around REBT for PWS. As a future SLP, the step-by-step nature of your intervention approach using REBT resonates greatly with me, as it separates and defines what each step of a more abstract practice like REBT will look like. The “acquired belief” that I hope to apply to any later clinical work with PWS was the belief that exploring the relationship of a person to their stuttering is necessary and encouraged. I think that type of thinking may be the fastest way to achieve greater fluency without being so focused on fluency itself. In a way, that belief somewhat humanizes the stutter itself, calming the PWS’s approach to his/her stutter by allowing him/her to view it as a thing separate from him/her, but still related/a part of him/her.

    My only question would be – is this type of therapy, in your view, helpful for Neurogenic/Psychogenic Stuttering as well as Developmental Stuttering? I feel as though REBT could be immensely helpful for all types of stuttering in terms of acceptance; though, REBT may not allow for greater measurable fluency in the populations of Neurogenic/Psychogenic Stuttering.

    Thank you for your work!
    Emily Schrader, Edinboro University of PA

    • Dear Emily,
      The work that I have done with persons with Neurogenic/Psychogenic Stuttering overlaps greatly in two areas: 1) how to accept oneself unconditionally with or without stuttering and 2) how to build frustration tolerance and be able to learn all the intricacies of fluency enhancing techniques without the danger of hopelessness, helplessness, and run of the mill impatience. When we strip the excess negativism from a situation the acquisition of skills is easier.
      I hope this clarifies the applicability of REBT.
      Gunars

  23. Hello Dr. Grossman and Dr. Neiders,

    I would like to thank you both for the very insightful article. As a first-year graduate student, I have not yet had the opportunity to work with individuals with fluency disorders; however, through clinical observations and my clinical sessions, I have observed that the core beliefs that hinder free-flowing speech in PWS are also present with individuals who have motor speech disorders and language disorders. I have noticed how individuals with other language and speech disorders are also susceptible to emotional and social issues stemming from their inability to produce speech and language effortlessly. I believe that the REBT practices that you have stated would also be very beneficial for individuals with other speech and language disorders. Therefore, I will definitely consider using REBT to assist future clients of mine.

    Additionally, I was wondering if REBT is most effective in individual therapy sessions or if it would have a greater impact on PWS in group therapy sessions. I read that when individuals are in a non-judgmental environment, they are less likely to stutter or experience the negative core beliefs that would hinder fluent speech. Therefore, if PWS are in a supportive environment with others that also have fluency disorders, is it more likely that they would change their negative core beliefs into more positive ones, especially after knowing that they are not alone with their disorder?

    Thank you,

    Rose

    • Hi Rose,
      I agree with what you have written in your first paragraph.
      As to which environment is better for recovery, that of individual or group settings, I staunchly believe in both/and logic. Meaning that both environments have their advantages and different clients will benefit to a different degree from either environment.
      When I read your last paragraph I wonder if there is not a bit too much emphasis on fluency instead of arriving at a set of beliefs and an emotional state that induces relaxed, task focused approach. And what is the task at hand? Answer: better communication, less emotional disturbance, and more engagement in life. Although I believe that supportive environment leads to more instantaneous fluency–this is not exactly what we are advocating. We are advocating free-flowing forward moving speech with minimum avoidances and emotional upset.
      I would also like to add, that our ultimate goal is to be able to perform in a neutral, hostile, or “I don’t know, nor am I overly concerned about the listener’s attitude” environment.
      Remember that I have shown great success with stripping out most of the anticipatory anxiety.
      If you want to pursue this thought further, please e-mail me.