Treatment of Stuttering in Adults
Additional Readings
Chapter 16: Treatment of Adolescents: Advanced Stuttering (Week 8).
Chapter 9: Avoidance Reduction Therapy for Stuttering (Week 9).
Next week's readings will be uploaded by Thursday.
Treatment Approaches
Fluency Shaping: Aims to modify speech to increase fluency.
Stuttering Modification: Focuses on changing the way one stutters to make it easier and less tense.
Acceptance-Based or Stuttering-Affirming: Emphasizes acceptance of stuttering and reducing negative emotions associated with it.
Controlled Fluency: Teaches techniques to control speech and reduce stuttering moments.
Camperdown: A treatment program that teaches prolonged speech techniques.
Fluency Plus: Combines fluency shaping and stuttering modification techniques.
Dr. Guitar’s Integrated Approach for Adults: A comprehensive approach tailored for adult stutterers.
Dr. Rodger’s Guiding Framework for Teens: A framework designed to support teenagers who stutter.
Avoidance Reduction Therapy for Stuttering (ARTS): Focuses on reducing avoidance behaviors associated with stuttering.
Blank Center Communication-Centered Approach: Centers on improving communication skills.
Dr. Rodgers' Guiding Framework (2025)
Learning about the speech mechanism: Understanding how speech is produced.
Identifying moments of stuttering: Recognizing when stuttering occurs.
Holding, tolerating, and easing out of stutters: Managing stuttering moments with less tension.
Making changes to talk and stutter more easily: Modifying speech patterns to reduce stuttering severity.
Education:
Reframing success: Redefining what success means in communication.
Identifying thinking traps: Recognizing negative thought patterns.
Accepting and letting go of difficult thoughts and emotions: Using acceptance and commitment therapy (ACT) principles.
Finding community: Connecting with other people who stutter for support.
Developing more positive attitudes and emotions about stuttering: Building self-esteem and confidence.
Reducing avoidance of sounds, words, and situations: Confronting feared speaking situations.
Disclosure:
Expanding the comfort zone: Gradually increasing willingness to disclose stuttering to others.
Voluntary Stuttering/Open Stuttering: Intentionally stuttering to reduce fear and build confidence.
Reducing avoidance of sounds, words, and situations.
Dr. Guitar's Integrated Approach
Focuses on the treatment of adults: Tailored strategies for adult stutterers.
Key Concepts
Treatment of adults is lengthy, requires motivation, and focuses on multiple aspects: Comprehensive and dedicated approach.
Treatment should be individualized: Tailoring therapy to meet specific needs.
Success depends on increasing approach behaviors and reducing avoidance: Encouraging engagement and reducing withdrawal.
Adults may have residual speech-processing deficits: Addressing underlying cognitive challenges.
Progress measurement is crucial: Tracking progress to ensure effectiveness.
Goals for Treatment
Focus on stuttering itself, not just fluency: Addressing the core issue of stuttering.
Reduce negative emotions: threat, fear, embarrassment, shame: Improving emotional well-being.
Teach staying in the stutter (open stutter) while calm and maintaining eye contact: Building comfort and confidence during stuttering moments.
Reduce tension and finish the stutter slowly and loosely: Promoting physical relaxation.
Produce typical stutters openly, without escape or avoidance: Encouraging acceptance and reducing struggle.
Maintain good natural eye contact: Enhancing communication effectiveness.
Therapy Goals: Feelings and Attitudes
Reduce fear (and avoidance) through counterconditioning and deconditioning: Overcoming anxiety through exposure.
Reduce shame through openness and “advertising stuttering”: Encouraging self-acceptance.
Reduce negative thoughts via cognitive therapy activities: Challenging and changing negative beliefs.
Elements of an Integrated Approach
Exploring Stuttering (catch and release): Understanding and managing stuttering moments.
Learning to Stay in the Stutter and Finish the Word Slowly: Reducing struggle and tension.
Increasing Approach Behaviors: Engaging more fully in speaking situations.
Maintaining Progress: Ensuring long-term success.
Steps in Exploring and Changing Stuttering (Table 17.1)
Understanding Stuttering- Activities: Discuss elements of stuttering with the client, show deep acceptance, and explain the logic behind core, escape, and avoidance behaviors.
Goals: Gain understanding of the mysterious and scary aspects of stuttering; begin desensitization.
Approaching, Exploring, and Changing Stuttering in the Treatment Room- Activities: Examine stuttering behaviors, catch and hold stutters, provide positive feedback, coach tension reduction, and model ending stutters slowly and loosely.
Goals: Continue desensitization and begin modifying stutters.
Approaching and Exploring Stuttering Outside of the Treatment Room- Activities: Observe stuttering and reactions, catch, hold, and slowly release stutters, discuss feelings, and audio record stuttering in various situations.
Goals: Continue desensitization, learn to tolerate stuttering with more listeners, and maintain control in stuttering.
Beginning Therapy
Determine client’s goals: Identifying what the client wants to achieve.
Map out treatment plan: Creating a structured approach to therapy.
Decrease fear and shame: Addressing emotional barriers.
Learn to manage stuttering: Developing coping strategies.
Transfer newly learned behaviors, emotions, and attitudes to daily life situations and maintain them: Ensuring real-world application and long-term success.
Exploring and Changing Stuttering
Understanding stuttering- Handout from book Discuss elements of client’s stuttering with her.
Client is guided to feel what she’s doing and describe her stutters.
Approaching and exploring stuttering in the treatment room- Clinician models catching and holding stuttering.
Client is guided to catch and hold her stutters.
Client is guided to hold and reduce tension in her stutters.
Approaching and Changing Stuttering Outside the Treatment Room
Clinician helps client develop a hierarchy of least-to-most difficult situations: Gradual exposure to feared situations.
Clinician models voluntary stuttering to strangers: Demonstrating comfort and acceptance.
Discussion of listener reactions to clinician’s voluntary stutters: Analyzing and understanding responses.
Client enters situations, studies her stuttering as it occurs: Observing and analyzing personal experiences.
Discussion of feelings about her stuttering, listener reactions: Processing emotions and reactions.
Approaching and Changing Stuttering Outside the Treatment Room
Client enters situations, attempts to hold onto her stutters and reduce tension.
Client voluntary stutters in public- If stutter becomes real, then stay in the stutter and ease out
Voluntary Stuttering
Challenging at first, but can have cognitive, affective, and behavioral benefits (Byrd et al. 2016, Grossman 2008).
Adults who stutter reported that voluntary stuttering provided (Plexico, Manning, & DiLollo, 2005):
A personal sense of freedom: Feeling empowered and in control.
Eliminated any potential for the listener being surprised by their speech: Reducing anxiety about unexpected stuttering.
Minimized fear that the listener would somehow discover that they had been trying to hide that they stutter: Reducing shame and secrecy.
Adults reported significant gains in quality of life after using voluntary stuttering provided that it was (Byrd et al., 2016):
Similar to their actual moments of stuttering: Practicing realistic stuttering patterns.
Context also important!
Used more than once beyond the (large ES) A “critical motiving factor” in the client being willing to do it, is YOU being willing to do it! (Manning, 2010).
Voluntary Stuttering as Described by an Adult who Stutters (Guitar, 2025)
Producing an intense pretend stutter leads to physical and emotional relief: Releasing tension and anxiety.
Tension release is felt in the chest, neck, and around the mouth: Experiencing physical benefits.
The brain may confuse it for a real stutter: Gaining neurological advantages.
There is satisfaction in controlling the created stuckness: Feeling empowered.
Increasing Approach Behaviors
Reduce avoidance, self-consciousness, and shame: Promoting confidence and self-acceptance.
Use feared words: Confronting linguistic challenges.
Enter feared situations: Facing social anxieties.
Maintaining Improvement
Client learns to become their own clinician using a textbook handout: Developing self-management skills.
Client sets personal goals and develops assignments: Promoting autonomy and responsibility.
This occurs gradually throughout therapy: Ensuring a smooth transition.
Other Stuttering Modification Strategies
Developed by Charles Van Riper (1973).
Preparatory set:
Easing-in technique Anticipating a moment of stuttering “Muscles in a position of readiness for speech, but not too tense”.
Cancellations:
After a stutter, go back and produce the word differently (typically less tense).
Avoidance Reduction Therapy for Stuttering (ARTS)
Addresses the learned avoidance behaviors: Targeting habitual avoidance patterns.
Aims to strip away hiding behaviors for comfortable communication: Promoting authenticity.
Overarching Goal:
To become an efficient, confident, spontaneous, joyful communicator by reducing avoidance:
Comfortable, forward-moving disfluency that does not interfere with communication.
What is Struggle?
Suppression of stuttering: Hiding stuttering moments.
Suppression of feelings: Avoiding emotional responses.
Suppression of thoughts: Controlling thoughts related to stuttering
Avoidance Reduction Therapy (ARTS) Goals
Decrease struggle and its consequences; comfortable disfluency will remain.
Support
The “power of the group”: Benefits of peer interaction.
Role models and accountability: Learning from others and staying on track.
Healthy competition: Motivating progress through friendly rivalry.
Giving and gaining support are equally valuable: Reciprocal support enhances outcomes.
In absence of group, identify a support person with whom they can check-in
Online communities of current and former ARTS members
ARTS Outcomes
Efficiency in Communication: Clear and effective speaking.
Comfort in Communication: Relaxed and confident delivery.
Confidence in Communication: Assurance in speaking abilities.
Spontaneity in Communication: Natural and unforced speech.
Joy in Communication: Enjoyment in expressing oneself.
Authenticity in Communication: Genuine and honest expression.
ARTS Values
Not Valued:
Fluency (fairweather friend): Perfect speech.
Control (any sort): Strict regulation of speech.
Hiding stuttering well: Concealing disfluencies.
“Practice”: Rigid drills.
Protecting others from discomfort: Avoiding difficult conversations.
Highly Valued:
Comfortable, forward moving speech: Easy and progressive communication.
Struggle-free speech: Speech without tension or strain.
Exercising choice - way you stutter: Freedom in how one stutters.
Revealing yourself as a person who stutters: Honesty about stuttering.
Change between sessions: Progress and adaptation.
Connecting with others
ARTS Goals
Goal 1: Knowledge to support change (understand the nature of stuttering and factors that maintain and perpetuate the problem).
Goal 2: Reduction of secondary escape behaviors.
Goal 3: To modify the moment of disfluency to produce a comfortable forward moving speech.
Goal 4: To face fear, allow thoughts, and take on the role of PWS (to reduce negative feelings and attitudes associated with stuttering).
Goal 5: To improve overall communication skills (engage in small talk, improve presentations).
ARTS: Redefining Success
Count it as a success if you:
Establish eye contact before beginning to speak.
Monitor well (observe exactly how you stutter).
Stutter, but bring the sound in immediately.
Stutter forward.
Stutter with good eye contact.
Go out of the way to enter a situation especially for your speech (take the initiative).
Put the hardest word first in the sentence.
Complete any feared word you start.
Choose feared words instead of "easy" words.
Mention your stuttering casually without shame.
Stutter without one or more of your tricks.
Cancel any failure.
Count it as a failure if you:
Substitute.
Look away, or up or down, during a block
Use a starter.
Stop half way through a block.
Do not have sound in the block (preformation).
Back up and start over.
Ruin an open stuttering assignment with fluency immediately afterwards.
Cover up your stuttering successfully.
Stall a long time before entering a situation.
Try to talk fluently at any cost.
Show embarrassment which puts your audience ill at ease.
Perform an assignment half-heartedly.
Respond quickly and automatically to every little pressure in the situation.
Give yourself the benefit of the doubt.
Use a crutch to get the word out.
Sample ARTS treatment goals and activities
Becoming an expert on your stuttering pattern: Understanding personal tendencies.
Helpful versus unhelpful behaviors: Identifying effective and ineffective strategies.
Stuttering Fingerprint: Detailed analysis of individual stuttering patterns.
Desensitizing to (tolerating) open stuttering: Building resilience to overt stuttering.
Stuttering directly on the feared sound/word: Confronting specific linguistic challenges.
Planning to feel shame per the fear hierarchy
Approaching and entering feared speaking situations: Facing social anxieties gradually.
Create personalized fear hierarchy (low, mid, high)
Take risks
Letting go of efforts to control:
Paradoxical challenges: Getting someone to grimace when you stutter
CBT, ACT, and narrative therapy activities
Enacting the role of a person who stutters
Voluntary stuttering
Self-disclosure (advertising)
Open Stuttering Sequence
Identify and “strip away” avoidance: Recognizing and eliminating avoidance behaviors.
“Ugly” stuttering (may skip): Initial, unrefined stuttering.
Voicing on block (reinforce any sound): Maintaining vocalization during stuttering.
“Clean stuttering”: Stuttering without secondary behaviors.
Stuttering that is free of linguistic and physical escape and avoidance behaviors: Authentic and uninhibited stuttering.
Adjust parameters of normal fluency:
Voicing.
Movement.
Tension.
Airflow.
Timing
Cognitive Messages
Let it go
Let it rip
Get sound in that block
Make it loud
Go for it
Jump on that sound
Jump on the moment
Hands off the wheel
Relax into the sound
Do nothing (say what first comes into mind)
Live in nervousnessStuttering Modification
Peel Back the Onion
Identify all the things you do to hide your stutter (“tricks”): Recognizing concealment strategies.
Rank from least to most used: Prioritizing these strategies.
Label as helpful and unhelpful: Evaluating their effectiveness.
Have someone else monitor, monitor someone else’s
Monitor avoidances (to self).
Raise a finger (to others).
Preparing for Difficult Thoughts and Feelings
Help client “plan for ” (shame, embarrassment, nervousness, etc.): Preparing for emotional challenges.
Growth can be uncomfortable, but if you do it a little at a time, it makes you stronger (desensitization)
Can feel empowering to feel these difficult thoughts/feelings, but do ACT it anyway, this is you “living your values” concept
Working with Difficult Thoughts and Feelings
Pairing targets with cognitive message:
”Let it rip”
”Eyes up”
“Connection is important”.
Working with Difficult Thoughts and Feelings
Cognitive restructuring work
Narrative therapy: naming/personifying the stutter, writing a letter to it, telling its “story”.
CBT: Reframing, checking the evidence, challenging thoughts
ACT: Choice point, cognitive defusion activities for specific difficult thoughts/feelings
Bilbliotherapy and cinetherapy (books and movies)
Exploring fear
If I stutter, they will , they will think I **, I will feel *_
Best case, worse case, most likely case
Pros and cons of speaking up in an upcoming situation
Sample ARTS Hierarchy
Show up.
Say more- run stop signs (tricks are allowed).
Say what you want to say, know it means risking a stutter (maybe still hoping you don’t).
Say what you want to say, prepared that if a stutter happens it will feel awful but I can tolerate it- Note, not preparing/saying that “It won’t be so bad”.
Say what you want to say, planning to stutter and planning to feel _ and let them think ____
General Session Outline
Assessment/Goal Review (“Successes”).
Target Practice:
Monologue, game
Discussion Topic.
Assignment Development (Home Practice)Who, where, define success
You can use this with any approach!
Discussion Topics Examples
Self-compassion, what does it look like?
Stuttering across cultures.
Neurodiversity and stuttering.
What are the things that other people might not know about stuttering? About the way you stutter?
What is grit? How does it relate to your experience with stuttering?
Don’t be a Hero!
For home practice, always start with low feared (or even no fear) situations and tasks and gradually increase difficulty
Desensitization vs. trauma
Many ways to visualize, talk about this
Low, mid, high fear situations
Circles of comfort (from Week 8 lecture)
Zone of optimal functioning
Some stress, but not too much
Blank Center CARE model
Communication-Centered Treatment (CCT) (Byrd et al., 2022; 2024).
Based on the CARE model: Communication, Advocacy, Resiliency, Education
“Empowering persons who stutter to speak confidently, communicate effectively, and advocate meaningfully such that the overall quality of their lives and the extent of their future aspirations are not defined by whether or not they stutter when they speak.”
Prevent the expectation of fluency in children, reject the expectation of fluency in adults
Manualized
ONLY targets affective and cognitive aspects of stuttering, fluency not targeted directly or indirectly
Two 60-min sessions per week for 12 weeks, one group, one individual
Has been piloted with children (Byrd et al., 2018; 2021)
Communication Effectiveness in Adults Who Stutter (Byrd et al., 2021)
Outcomes (Communication Effectiveness)
(1) Language use (e.g., expected opening/closing remarks? formal language appropriate for interview?)
(2) Organization (e.g., open with small talk? on topic or wandering? succinct?)
(3) Speech rate (e.g., rate easily understood and varied for emphasis? rate slowed to highlight key points?);
(4) Intonation (e.g., pitch varied and not monotone? pitch heightened to highlight key points?);
(5) Volume (e.g., volume varied and strong enough to be heard? elevated to highlight key points?);
(6) Gestures (e.g., hand movements to emphasize key points? hands visible? gripped hands or crossed arms? hands rubbing legs or in pocket?);
(7) Body position (e.g., appropriate body posture for interview? closed or restricted posture? did they “own the space”? were there distracting movements?);
(8) Eye contact (e.g., looked at listener? only looked in one direction or avoided eye contact?); and
(9) Facial affect (e.g., face visibly comfortable and interested? smiled occasionally to demonstrate interest in topic?).
Exit Ticket
How does Dr. Guitar’s integrated approach and ARTS hit all of the ABCS of stuttering? List one activity or concept from for each of the ABCS.
Fluency Shaping Approaches
Fluency shaping techniques for adults who stutter.
Controlled Fluency #1 (Guitar, 2025)
This is for clients with little fear of stuttering, who are comfortable with themselves, and have good social-conversational skills.
Fluency Shaping teaches clients how to use “controlled fluency” to eliminate or significantly reduce their stuttering.
It consists of learning to speak in a controlled style and then gradually change that controlled fluency into spontaneous fluency.
Controlled Fluency #2
Learning controlled fluency involves these skills:
Flexible rate—being able to slow down speech rate enough so that stutters are eliminated.
Pausing—putting in pauses at natural places so that the speech production system has extra time to process.
Easy onsets—beginning a word in a very slow and easy manner so that stoppage and tension do not occur.
Light contacts—touching the articulators very gently, without full stoppage so that tension does not occur.
Proprioception—focusing attention the feeling of articulator movement. This replaces the need to use auditory feedback to control speech.
Controlled Fluency #3
Client can learn these skills individually and then combine or learn them as a single combined skill from clinical model.
Move up linguistic and situational hierarchy
Client learns to use “cancellations” for times when she is unsuccessful at using controlled fluency to replace stutters.
Cancellations = after finishing stuttered word, pause, and say word again, but with controlled fluency.
Camperdown
Client taught prolonged speech (PS) in individualized sessions, which is transferred to real world Clients practice prolonged speech with a goal of sounding more natural.
Therapy happens in stages that take approximately 10-20 hours to complete
Stage I: Teach treatment components
Stage II: Establish natural-sounding stutter-free speech with clinician
Stage III: Generalize
Stage IV: Maintain stuttering control
Some