About the authors:
At the American Institute for Stuttering, we have found many benefits in moving away from placing primary importance on physical management strategies. In doing so, we find our clients realize more sustainable, significant improvements. The purpose of this paper is to outline a rationale for utilizing clinical strategies other than “speech tools” in stuttering therapy and to provide a few examples of therapeutic alternatives.
There are many reasons for this shift in treatment. First, it is common for children and adults who stutter to show great proficiency using, for example, easy onsets or pull-outs in the clinical setting but who find it difficult or nearly impossible to transfer the skill into real-life situations. When the use of the “tool” is the main goal, this difficulty with use in real-life situations only adds to feelings of failure and frustration. In addition, by concentrating on physical management of stuttering, we may be further reinforcing in clients’ minds that stuttering is something that is negative, and to be avoided. We know that for many, this dynamic only increases communicative fear, physical secondary behaviors, and avoidance of words, people, and situations.
So, for many clients, rather than teaching and training speech modifications, we work on changing negative beliefs about stuttering, building communicative confidence, reducing avoidance behaviors, and becoming truly fearless communicators. Below, we provide some specific ideas, when the speech toolbox isn’t the focus.
Adults & Teens
Alternative objectives for adults:
- Focusing on forward movement or “flow” is a helpful way to reduce the use of filler words or running starts. Also, many adults or teens who stutter will hit a threshold in a stuttering block where they will feel as though the word will never come out unless they back up and start again or resort to another coping behavior. We find that when a person can become more aware of this pattern, and learns to stay in the block, they can break the habit of retreating or recoiling from a block.
- Dedicate time to discussing what it means to be a good communicator. Discuss the cost of avoidance and coping behaviors and discuss ways to prioritize effective communication (i.e., better eye contact, volume, posture, etc) over trying to not stutter.
- Spend time in therapy exploring the art of public speaking. Ask the person to consider, outside of stuttering, what they could improve about their public speaking skills, and spend time working on it.
- Reframe negative beliefs by testing them out in the real world. If a client shares that he believes he will get hung up if he stutters, have him test this belief by making a phone call with the intent of getting hung up (it’s harder than you think!). Additionally, have him try self-advertising at the start of the call (you might need to demonstrate this first!) and see if that makes things easier.
- Promote greater mindfulness before, during, and after experiences with stuttering. We like to call this “noticing work.” Often times, people who stutter remove themselves mentally from the moment of stuttering; it feels like an out of body experience. Improving mindfulness during stuttering moments allows the individual to become more aware of the habitual aspects of their stuttering.
- Encourage clients to engage in discussions about stuttering with family, friends, and even strangers. The more they talk about it, the less “unpleasant ” or stigmatized it remains. One way to do this is to create a friends and family survey to be administered by the client. This helps to get the dialogue started, and often provides you, as the therapist, with a lot to talk about in sessions with your client.
With kids, many of the same principals apply. We need to keep in mind that it is very difficult for most adults to alter their habitual way of speaking, and that challenge is even greater for children. We may find it easy to speak slowly and deliberately for a short while, only to quickly “forget” and fall into our habitual pattern. Try speaking slowly and deliberately for one whole day and you’ll quickly see what we mean!
For children, rather than providing frequent reminders to use speech tools, it is more helpful for their caregivers to model a more thoughtful, relaxed mode of communication. We encourage parents to convey in word and action that what their child says is important, regardless of his/her fluency, to reduce time and communicative pressure whenever possible, and to maintain an open communication with their child about stuttering.
Alternative objectives for kids:
- Teach the child to self-disclose and educate others about stuttering: Help them create a letter for their teacher or counselor, role-play answering questions about stuttering and responding to teasing by classmates, create an informational brochure for distribution among friends.
- Address apprehension by communicating in specific situations: Create a hierarchy to approach these situations by modeling and encouragement, and target situations with intrinsic reward (for example, after calling and finding out that a store carries a specific candy, we then go there and buy some). In order to encourage children to communicate more openly, we have them complete surveys where they question others about a favorite food, toy, or tv show, usually having them self-disclose that they stutter and are working on their speech.
- Emphasize communicating well: Encourage eye-contact, adequate vocal volume, and use of full sentences regardless of stuttering and create situations where the child is praised for effective communication. Have them complete functional activities such as reading stories or how to play a game, without fluency being the focus.
- Praise the child for “stuttering well”: In other words, reinforce stuttering that is forward moving and that conveys the message authentically and without avoidance or recoil.
- Encourage the child to play around with his/her stuttering. Reinforce the positives of being able to do something different in a moment of stuttering (bouncing, stretching, increasing or decreasing tension), and help them understand that they can be the ”boss of their own mouth.”
As a closing thought, we think it is important for clinicians to not only consider these ideas, but also be able to thoroughly understand and explain the rationale for this approach. Clients, parents, teachers and other caregivers often expect therapy to be all about learning tools. It is up to us to change that perception.
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