Speech Language Pathologist (SLP) working with Mental Health Professional (MHP) with People Who Stutter (PWS) for better therapy outcomes – Michael Sugarman

About the Author: After 35 years I have retired with Master Business Administration & Master Social Work Degrees – Director of Social Services; facilitated support group and provided counseling to parents, family members, partners, and patients with Cancer, AIDS, Anxiety and Depression. Trained and worked at Stanford Medical Center, Humana Hospital and Alameda Health System. Attended International and National conferences for Disability, Cancer, AIDS and Stuttering. Former Executive Director National Stuttering Association (NSA0 1978 – 1982 and 1995 – 1997. Former Chair of the International Stuttering Association and the Consumer Affairs Division for the International Fluency Association. Honored by the American Speech and Hearing Association, International Fluency Association and the National Stuttering Association.

This paper is an example of speaking my mind to suggest that Mental Health Professionals be involved to address mental health issues with Speech Language Pathologists in treatment for People Who Stutter (PWS).

Title: Speech Language Pathologist (SLP) working with Mental Health Professional (MHP) with People Who Stutter (PWS) for better therapy outcomes

Imagine trying to order a hamburger while stumbling and hesitating over the first syllable. The waitress is waiting and finally you give up and order a cheeseburger—only because its easier to say. For millions of PWS this is a shared experience, one of the many that can lead to a sense of futility and retreat from social activity.

Peer and Professional Support Group

Peer support refers to PWS helping each other by listening, sharing common experiences, exploring options and empathy.  PWS can provide peer counseling in a variety of settings including one-to-one or peer support group. Peer support groups are not meant to replace professional led groups. Peer and Professional led support groups provide a setting for PWS to address: “we are not alone” (Peer and Professional), acceptance (Peer and Professional), and coping and management of psychosocial issues and fluency (Professional). By the 1990s, MHP respected the distinction between peer and professional led groups.

Addressing Fluency and Mental Health issues

Nina G. PsyD “Stutterer Interrupted: The Making of a Stuttering Stand Up Comedian” Soon to be published. Nina G. updated Dr. Sheehan’s iceberg analogy: (Referenced in her book)

Dr. Sheehan’s: Isolation, Fear, Hopelessness, Shame, Denial, Anxiety, and Guilt

Nina G.: Acceptance, Pride, Kindness, Community, Comfort, Courage, and Hope.

In addition, MHPs and SLPs may deal with other issues in therapy: education, fluency, employment, self-advocacy, civil rights, stigma, relationships, empowerment, change, love; “I stutter” and “Person who Stutters.”

MHP (licensed psychologist, licensed clinical social worker, licensed marriage family therapist) incorporate skills to navigate and manage a variety of mental health concerns. As well, SLPs are equipped to assist PWS in speech/fluency with mindfulness techniques along with Cognitive Behavior Therapy, Acceptance Commitment Therapy, Dialectical Behavior Therapy, Vivian Siskin’s Avoidance Reduction Therapy for Stuttering or Motivational Therapy.  SLP’s can decide to integrate a Licensed MHP for individual therapy or support group facilitation.

Future is Now

There is a history of treating PWS by a MHP with a SLP. For example, Dr. Joseph Sheehan was a psychologist working with his wife Vivian Sheehan SLP in individual therapy and support group therapy setting.

I would encourage SLP’s to consider working together with a MHP to address mental health and fluency issues

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Speech Language Pathologist (SLP) working with Mental Health Professional (MHP) with People Who Stutter (PWS) for better therapy outcomes – Michael Sugarman — 55 Comments

  1. I think SLPs working with MHP when addressing clients who stutter is such a wonderful idea. Do you know if there is any evidence that this type of double treatment improves client feelings toward therapy? Or reduces their stutter?

    • Hello and thanks for your question: Menzies is a clinical pysch in Australia using CBT, Vivian Sissken is a SLp and was trained at UCLA by Vivian SLPand joe Sheehan psychologist and integrated both approaches. Please google them.
      You have options in mental health: using a psychologist, clinical social worker or marriage family therapst..you can google the profession in your local to find resources to work with you. You’ll be cutting edge. Good luck

  2. Michael, Thank you for your insights. As a speech-language therapy graduate student, I had the opportunity to participate in a fluency camp that combined counseling and speech therapy treatment. The counseling component was a vital part of the experience for the clients. Have you had experience with combined treatment? If so, what was your impression?

    • I think we are in a new phase for stuttering therapy. Ross Menzies is a clinical psychologist and doing interesting work in Australia with speech language pathologist. Google him and see I what you think. I am retired from social work. And work with a range of mental health diagnoses. I had a couple of patients who stuttered and were in my CBT anxiety group. Have not worked with SLP. Good luck and by integrating MHP you’ll be breaking new ground.

  3. I so agree Michael, that there should be much more cooperation between SLPs and MHPs. And why not even therapists that work with relaxation, breathing, or maybe even public speaking experts! We are all so different, stutter in so many different ways, with so many different backgrounds and experiences. There is no one-fix-for-all. SO the more open minded therapists are, and involve those who are a perfect complement to that very client, the more we can achieve. Thanks for giving us the ISAD and keep talking. You are a wealth of knowledge.

    • Anita thank you for continuing what we started…Social Workers are using mindfulness practices along with cognitive behavior therapy with clients. I feel we are now entering another phase to address PWS needs. Check out what Ross Menzies clinical psychologist from Australia doing with SLP’s. Hope to see you in Iceland. I hope 🤞 SLP’s are not threatened by working with social workers or other mental health professionals…

  4. I agree (as a PWS who was married to a MHP). If the speech pathology profession did not exist and we had to invent the ideal clinician to treat stuttering, the result would be a hybrid, multidisciplinary critter. SLPs who specialize in stuttering have acquired counseling skills and often do an excellent job. However, they may not be equipped to diagnose a mental health condition, such as clinical depression, that may get in the way of working on stuttering. As you have indicated, a SLP-MHP partnership would expand the toolbox and result in more treatment options.

    • Jim thanks for your comments. Absolutely SLP’s are integrating counseling. Here’s what MHP can do and you can ask wife. MHP can use phq9 for depression screen and read that slp’s Are going to use anxiety screen. Fast forward to we may disagree however it’s good to talk about support groups. In the 90’s at Stanford medical center worked on developing skill manuals for professionals to work from in groups. For example, dialectical behavior therapy and cognitive behavioral therapy. So in our community SAy offers a SLp. Check out Ross Menzies clinical psychologist from Australia on his work with SLP’s. There is room for peer support. Professionals SLP and MHP offer a bit more and have a skilled set to address many more issues for PWS. Hope we can talk more. We are in the process of changing SLP and integrating MHP. Great time ..

  5. What a great article advocating for interprofessional collaboration! This is a new but very effective concept for disorders expanding beyond fluency. You hit on the point of stuttering being multidimensional; There are so many factors and emotions that can accompany it. Working with MHPs provides the individuals with additional supports. This is a great idea to consider, based on the client and timing of course.

    • 🙏🏻 we are now at the cutting edge of creating a positive therapy experience for PWS.

  6. What a great article! I think integrating the practices of SLP and MHP is a crucial component in assisting clients in speech therapy. There is just as much of a counseling aspect that needs to be addressed as there is a speech aspect. Is there evidence claiming one setting with an SLP and MHP more effective than the other? For example, a group setting vs individual therapy?

    • Thank you for your comments. We are looking at interprofessional collaboration to benefit PWS in therapy. Ross Menzies is a clinical psychologist using CBT skills. He is from Australia.
      Waiting for research to determine effectiveness to this approach. I am retired social worker. I am hoping a SLP sees the article and may try it.

    • Hello and thank you for your comments. We are entering uncharted territory with only a few references. We have to go back to joe Sheehan psychologist and his wife Vivian to examine their roles. We are talking almost 50 years ago. So I would suggest mental health professional facilitate group and slp complete one to one. This is wide open for you and MHP. Good luck

  7. Michael,
    As a speech-language pathology graduate student, we have spent a lot of time in class talking about the importance of addressing thoughts, feelings, and beliefs with our stuttering clients before utilizing any speech strategies. I had never thought about incorporating a MHP into individual therapy, but I truly think that having a counseling professional in the room could help mediate conversations about the client’s feelings towards their stutter. Do you know of any research related to what ages utilizing a MHP in therapy is most appropriate? Or do you feel that MHPs should be involved in therapy only in more severe cases?

    • Hello Tori, we have to go back 50 years and examine how joe sheehan a psychologist facilitated groups and his wife Vivian SLP did one to one counseling. So this area is wide open for you to establish a relationship with MHP. I don’t recommend 2 therapists for 1 hour session. You can google Ross Menzies in Australia. He is psychologist working with CBT skills.Its a very
      Exciting times! Good luck

  8. Hi am a student at the University of Minnesota Duluth and am currently enrolled in an advanced fluency disorders course. I have had some experience working with children who stutter and have recognized that counseling/mental health support would be beneficial for these individuals. I have heard of inter-professional collaboration, but I have not heard of sessions where mental health professionals and SLPs provide therapy simultaneously. Is this common in Australia, since this is where the research has been used? Has this double approach worked for all age groups? Lastly, have you personally been a part of this approach and seen positive results?

    • Hello,
      I am not a SLP. And I am a retired Social Worker. Joe Sheehan psychologist facilitated groups and his wife Vivian SLP offered speech therapy. Google Ross Menzies in Australia. You have opportunity to create your own practice. A MHP can facilitate a group on anxiety. And you can do individualized therapy on stuttering. I do not recommend in individual therapy both are present…to confusing. Good luck in creating a beneficial therapy outcome. I

  9. Hi Michael – I too support the idea of including MHPs in the treatment of stuttering, but at the same time, I’m pessimistic as to the likelihood of that becoming the norm anytime soon. I like what Anita suggests too – relaxation, meditation, breathing, public speaking. In fact, I think it makes MORE sense to engage those resources rather than an SLP who is going to focus on the speech mechanics. Addressing and minimizing avoidance behaviors should be the absolute first priority. Thanks for your essay!

    • Interesting…mental health professionals can do many of the tasks you mentioned. I know many PWS use toastmasters as a place to practice speaking.
      Thank you 🙏🏻 about integrating MHP… I know you Feel pessimistic. I can only hope and be optimistic. Maybe one day we can chat…

    • Hi Dori. Good to connect with you here. As you might expect, I’d like to note that many SLPs focus on more than just speech mechanics. We may address the affective and cognitive aspects of stuttering; promote development of overall communicative competence, whether fluent, disfluent, or stuttering at any given time; help to reduce avoidance behaviors and promote open communication; and foster acceptance, among other things. In fact, in a approach such as Avoidance Reduction Therapy, we may not even work on speech mechanics at all. In my school district, we have adopted a model of Basic Principle Problem Solving that takes a comprehensive approach to stuttering therapy and prioritizes development of overall effective communicators, and I am resourced to consult and collaborate with my SLP colleagues and provide continuing education. Increasingly, our field looks to other fields, such as neuroscience and psychology, to support and optimize what we do. It is not uncommon to see SLPs integrating Cognitive Behavioral Therapy (CBT), Acceptance and Commitment Therapy (ACT) and/or mindfulness practices into their therapeutic approaches. I know that you are pessimistic, but I am increasingly optimistic. One more thing. Sometimes it IS important to focus on speech mechanics. People who stutter are a diverse group, and many people value improving fluency and reducing stuttering symptoms. As SLP’s we need to provide a variety of therapy approaches to meet the varied needs of people who stutter and help them reach valued outcomes. Best,
      Rob Dellinger

      • Rob, thank you in answering Dori what SLP’s are creating in therapy relationship for PWS.

        Mike

  10. As an SLP graduate student, I completely agree that SLP’s should consider working alongside MHP to address mental health and fluency issues. Dr. Sheehan focused on helping clinicians look at both the ‘surface’ and ‘below surface’ features of stuttering in his iceberg analogy. I am curious to know what advice you have for SLPs targeting the ‘below surface’ features? I would also like to know if there is any supporting evidence of reducing an individuals stutter when SLP’s and a MHP work together?

    • Hello, Good questions. We are in uncharted territory at the moment. Look at Ross Menzies from Australia clinical psychologist using CBT skills with PWS. Remember Joe Sheehan was a psychologist t and his wife was a SLP. So in this article is suggesting SLP to work together with MHP. Also, your
      Field is doing
      Teaching of CBT and ACT skills. You’ll be able to do more ‘under surface’ work with clients when you feel comfortable using those skills. Good luck you are in changing times.

  11. Michael, I’m glad you posted on SLP/MHP collaboration in stuttering. In addition to Menzies’ work on CBT and stuttering, a couple of things that come to mind are Janet Beilby’s pioneering work in ACT and stuttering, and Mike Boyle’s application of mindfulness practices to stuttering. Many SLPs are drawing from fields such as neuroscience and psychology to improve our ability to support clients and optimize what we do. For me, ACT principles inform everything I do in stuttering therapy. I would like to see SLPs increasingly expand this approach to embrace working more directly with MHPs. My workplace, the public schools, would seem to be a natural environment for such collaboration to occur, e.g. with school psychologists and counselors, but in practice, meaningful and consistent collaboration can be challenging. At any rate, I am optimistic about the future. As Noam Chomsky notes, “Unless you believe the future can be better, you are unlikely to step up and take responsibility for making it so”! Best,

    Rob Dellinger

    • Thank you for the Chomsky meaningful quote. Loved it.
      So, times are changing to benefit PWS in therapy. Let me see if MHP’s can offer additional help. Before retired facilitated anxiety and depression management group. And another therapist facilitated a mindful depression management group with a psychiatrist. So, MHP can bill insurance for anxiety and depression group management -maybe a SLp be willing to facilitate a group with MHP.
      Times are changing!

  12. I think SLPs and MHPs are a good compliment when addressing the field of fluency. I love hearing about the increased interest in it. I was wondering about what your thoughts were on role release with SLPs and MHPs working with each other. Have there been concerns or difficulties with it?

    • Thank you for your comments. I share similar thought that Slp and MHP can work together in a treatment plan for PWS. I only know of Menzies psychologist from Australia using CBT with clients who stutter.
      Treatment plans are in a new phase of therapy. Maybe using MHP facilitating support group by addressing anxiety and depression management. or co facilitating with SLp. Waiting to review Menzies research to help determine benefits of MHP. Good luck in your work with PWS.

  13. Hi, Michael. Thank you for sharing. I am a speech-language pathology graduate student currently taking a course on fluency. I support the idea of SLPs and MHPs should working together to improve therapy outcomes for individuals who stutter. Do you think this approach is appropriate for people of all ages (e.g., a 4 year old vs a 40 year old)? How might the collaboration between SLP and MHP be different/the same?

    • Hello, Good luck in your studies and creating a new phase of therapy. I feel we are in new territory. So, I would try a MHP with SLp during group sessions. As MHP facilitated professional support groups for 30 plus years for 18 and up. There are MHP who specialize in teens. I would hope SLP’s would try…to use MHP. The most important is both professionals are on the same view. Good luck again.

  14. Hi Michael,

    Thank you for sharing. I am a SLP Graduate student and I’m passionate about combining mental health with SLP, treating the individual more holistically rather than compartmentally. I have looked into some of Menzies’ research and find it fascinating. Do you think it’s acceptable for an SLP to be trained in mindfulness, CBT, and ACT and implement them in therapy when access to an MHP may not be available?

    Thanks,

    Colton

    • Yes to your questions. And your plan to implement those skills in your treatment plan for PWS. I think MHP can co lead with SLP and be helpful in facilitating support groups and address depression and anxiety management. You. Are breaking new territory and good luck in becoming SLP.

  15. Hi Michael,

    Thank you for this article! I think the combination of MHP and SLP’s should be utilized more often. Is this something that an SLP has to be intentional about seeking out, collaborating with a MHP? Do MHP’s often know to be tuned into the stuttering population? What is your take on this?

    Sincerely,

    Stephanie

    • Hello,

      Really good question. MHP are exposed to variety of diagnoses- For example I was social worker during onset of AIDS epidemic. And facilitated support group and provided one to one therapy. So I think the relationship between SLP and MHP is the key. MHP can facilitate groups to address anxiety and depression management. You are breaking new ground so good luck.

  16. Hi Michael,

    Thank you for sharing. I am a graduate student studying speech language pathology and am currently in a fluency class. I believe that counseling is such an important component in addition to the therapy process. As a future speech language pathologist, I think an important part of my job will be the provide people with the resources that they need outside of therapy such as counseling with a MHP and support groups. During speech therapy sessions where a MHP may not be present do you have any advice on some general counseling information that a speech language pathologist could use during a session?

    Thanks,
    Emily

    • Hello, Good question. I think when you feel comfortable with therapy skills such as Cognitive Behavior Therap, Mindfulness or Acceptance Commitment Therapy. And a skill you may want to be expose to is dialectical behavior therapy. The more comfortable you are you client will be more comfortable with you and change can occur. good luck in becoming a therapist.

  17. Michael,
    I very much agree with your ideas on having the two professions work together. I am currently a freshman in college and am majoring in Speech Language Pathology. I hope to find ways to integrate many professions and practices in my studies, in order to give my patients the most beneficial treatment for their personal situation. Thank you for being an advocate for this community.

    Thanks,
    Natalie

    • Thank you for your kind comments. Good luck in forging therapy skills to benefit PWS.

  18. Hello Mr. Sugarman,

    Thank you for this article. Another paper presented in this conference wrote of the benefits of involving the parents of young people who stutter in therapy to enhance client outcomes. I wonder- is it possible the benefits of a peer support group for young people who stutter may be augmented by parental involvement in some capacity?

    Thank you for your time,
    Blaine

  19. Hello, Good question. Peer support groups are extremely helpful talking with others that have the same condition. Professionals have a set of skills to alleviate shame and develop communication skills between young child that stutters and parents. Parent and child can benefit from both peer and professional support.

  20. Michael,

    Thanks for bringing this topic and research to this conference. I am an SLP graduate student and we are learning how incorporating counseling as part of fluency therapy is so important. Since stuttering typically causes PWS anxiety, it is important to talk about those feelings with the right professionals. Including MHP in the therapy process is really important because there are emotions and feelings that SLPs are not equipped to help people work through. Interprofessional collaboration is crucial for everyone to get the proper and complete care they deserve. Thanks again for your insight and perspective on this aspect of therapy!

    -Katy

  21. Hello Michael

    Thank you very much for writing about SLP and MHP collaboration. The discussion going on here in response to your paper is interesting and encouraging. While I understand’s Dori’s pessimism about such collaboration actually happening, I am encouraged by Rob’s descriptions of how (some) SLPs already incorporate tools to address the emotional issues that might be present in PWS.

    In Israel, Dr. Ittai Glick, a PWS and clinical psychologist, has worked with SLPs to learn and teach ACT to SLPs, and for ACT to be incorporated into the SLPs treatment approach. This is happening slowly, but happening. We have great support from Dr. Ruth Ezrati, a prominent SLP, teacher and researcher in the field of stuttering.

    However, we do need to expand the dialog, and expand the practice of collaboration between SLPs and MHPs, not least because some mental health issues will be beyond the scope of what the SLP, however talented, can do. We have a case of a boy who stutters who attempted suicide. It is not clear if stuttering was the trigger, as there are many other factors in this complex case. Here, exactly, is where SLP/MHP collaboration would do wonders, in my opinion.

    Thanks a lot
    Hanan

    • I hope the person attempted received MHP treatment. Our discussion has now led me to discuss PHQ9 depression screen. Every patient that came to our clinic had to complete this screenunderdtand that in health cate at hospitals we use Epic or Nexgen. And that will calculate and to determine treatment plan for a patient. You can go online and review the depression screen and ask whether it’s feasible for SLP to administer the screen as part of the initial assessment. Look forward to discussing this more.

      • Hanan, The relationship between MHP and Slp is vital. MHP skills can either lead or lead a support group…MHP skills can help manage anxiety or depression. More to discuss

  22. Hi,

    I enjoyed reading your piece. I am a current graduate student in Speech Language Pathology so this was a very insightful reading. We have learned a lot about how important the counseling aspect of this field is and that it is important to know when we are dipping our toes into something outside of our scope of practice. I agree that SLPs should be collaborating with a MHP when working with PWS. How would you recommend that an SLP goes about that collaboration and when would it possibly NOT be appropriate for that collaboration. Or do you think that they should always work together with PWS.

    Thank you in advance,
    SC

    • Good question. I am thinking out loud… you are forging a new road. During the initial slp assessment you can ask PWS to complete a PHQ9 depression screen. Now remember being a MHP in hospital every patient that comes to our clinic completed a depression screen The numbers are calculated by software program Epic or Nexgen to assist in determining treatment plan. Before you do anything you’ll need to discuss with our clinic supervisor. Remember this is new…MHP can either lead or co-lead with SLP support group. MHP are skilled and trained in anxiety and depression management.

    • Good question. You as SLP is the lead. You can decide on whether to collaborate or refer client to a MHP. You determine your own skills whether you can help a client. And remember it’s a reflection on your skills if you collaborate. In my experience I was unable to do therapy with a patient and made appropriate referral. Good luck on forging new paths and adventure.

  23. Hi Michael,
    I am glad you’re championing this method of collaboration as a treatment option. I fully believe that there are great benefits for PWS to collaborate with a team of peers AND professionals who use different techniques to achieve the same goal. As a student and teacher, it’s important to acknowledge that each person responds, grows and learns in different ways. Having a team with an MPH and SLP ensures different types of support for PWS. I know personally, SLPs have training for fluency treatment and counseling, but another professional with counseling experience that can delve further outside of our scope of practice is a helpful key to emotional progress. Thank you for sharing!
    AY

    • I agree. Benefits to peer support is needed. And SLP’s have and learning skills CBT and ACT to address many complex issues. And MHP are trained to either Co lead therapy groups or address Mental Health issues. All to benefit PWS. Good luck.

  24. I think addressing mental health along with speech therapy is an amazing idea especially when working with children and teens who stutter because it is important for them to have a positive attitude. Are there many programs that have started to address both speech and mental health together?
    ~shelby

    • No and not yet. Forging a different approach is often difficult…however rewarding. Probably the most important dynamics is your relation with MHP and differentiate roles. For example
      Maybe co lead a support group. Good luck in forging a new path. You can google Menzies psychologist from Australia is working with PWS and using CBT skills.

  25. Hello,

    I am also a SLP grad student who is currently in a fluency class. Intra-professional collaboration is a common discussion in my classes. I agree that MPH and SLP collaboration as a treatment option is very beneficial for PWS. Each professionals brings different knowledge and expertise to the therapy. I was wondering if you have ever experienced, in your own collaborations during this type of approach, where one professional has gone outside the scope of their own profession? If so, how did you or others handle the situation? If not, do you think that this could happen to others during this approach?

    • Good question. I am not a SLP. I am retired MHP. And collobaratef with a nutritionist and psychiatrist for anxiety and depression management by using dialectical behavior therapy and cognitive behavior therapy. Google Ross Menzies psychologist who cognitive behavior therapy approach with PWS. Good luck in using CNT and ACt skills.

  26. This was such a great article! Collaborating with other professionals is so important when providing therapy services to PWS. Working with MHPs could provide additional support and help individuals manage and cope with different emotions or mental health concerns. As an SLP grad student, I think this is a great idea to consider and learn more about in order to implement in future therapy sessions. When considering the necessity to provide emotional support but also the concern presented to stay within the SLPs scope of practice, intra-professional collaboration would be a great solution!