Treatment of Stuttering in Adults

Treatment of Stuttering in Adults

Additional Readings

• Chapter 16: Treatment of Adolescents: Advanced Stuttering (Brightspace Week 8)

• Chapter 9: Avoidance Reduction Therapy for Stuttering (Brightspace Week 9)

• Next week's required readings will be uploaded by Thursday.

Treatment Approaches for Adolescents and Adults

• Fluency Shaping

• Stuttering Modification

• Acceptance-Based or Stuttering-Affirming

• Controlled Fluency

• Camperdown

• Fluency Plus

• Dr. Guitar’s Integrated Approach for Adults

• Dr. Rodger’s Guiding Framework for Teens

• Avoidance Reduction Therapy for Stuttering (ARTS)

• Blank Center Communication-Centered Approach

A Guiding Framework (Rodgers, 2025)

• Learning about the speech mechanism

• Identifying moments of stuttering

• Holding, tolerating, and easing out of stutters

• Making changes to talk and stutter more easily

• Education- Reframing success

  • Identifying thinking traps

  • Accepting and letting go of difficult thoughts and emotions

  • Finding community

  • Developing more positive attitudes and emotions about stuttering

• Reducing avoidance of sounds, words, and situations

• Disclosure- Expanding the comfort zone

  • Voluntary Stuttering/Open Stuttering

  • Reducing avoidance of sounds, words, and situations

Dr. Guitar's Integrated Approach to Stuttering Therapy for Adults

Key Concepts

• Treatment of adults usually takes a long time, demands considerable motivation, and must maintain a focus on many fronts.

• Treatment should be tailored to each client’s needs.

• Successful outcome of treatment depends, in part, on increasing approach behaviors and reducing avoidance.

• Adults who stutter may continue to have speech-processing deficits after treatment and may need to continue to deal with them.

• Measurements of progress and outcome are important.

Goals for Treatment of an Adult who Stutters

• Focus of therapy is on stuttering (not fluency)

• Reduce negative emotions associated with stuttering: threat, fear, embarrassment, shame.

• Teach client to stay in stutter (or open stutter) while remaining calm, being comfortable in stutter, allowing tension to reduce, keep good eye contact.

• When tension is reduced, finish stutter slowly and loosely.

• Typical stutters produced openly, without escape or avoidance behaviors.

• Good natural eye contact maintained.

Goals of Therapy: Feelings and Attitudes

• Need to reduce fear (and avoidance) - Requires counterconditioning and deconditioning

• Need to reduce shame - Requires openness, “advertising stuttering”

• Need to reduce negative thoughts - Requires cognitive therapy activities

Elements of an Integrated Approach to Treatment

• Exploring Stuttering

• Learning to Stay in the Stutter and Finish the Word Slowly

• Increasing Approach Behaviors

• Maintaining Progress

Steps in Exploring and Changing Stuttering

Understanding Stuttering

Activities:

• Provide handout and discuss the elements of the client's stuttering with them. Clinician shows deep acceptance of client as they are now and shares the perspective that there is a logic behind what the client currently does in their core, escape, and avoidance behaviors.

Goals:

• To gain an understanding what has been mysterious and scary; beginning of desensitization

Approaching, exploring, and changing stuttering in the treatment room

Activities:

• Clinician and client examine client's stuttering behaviors. They then catch and hold stutters. Clinician showers client with positive feedback as they stay in a stutter and learn to feel what they're doing physically when they stutter. Clinician coaches client to feel tension reduce until the word can be completed. Via the clinician's modeling and coaching, client learns to end stutter slowly and loosely.

Goals:

• Continuing desensitization. Beginning of learning to modify stutters

Approaching and exploring stuttering outside of the treatment room

Activities:

• Client and clinician observe stuttering and client's reactions to it outside the clinic. As the stuttering is studied, client tries to catch, hold, and slowly release stutters outside of the treatment room. Continuing discussion of how client feels about their stuttering. Audio recording by client of their stuttering in various situations followed by discussions with clinician.

Goals:

• Continuing desensitization. Client learns that they can tolerate their stuttering with more and more listeners. Client learns to stay in stutter until they can reduce tension and finish the word with a feeling of control

Beginning Therapy

• Determine client’s goals

• Map out treatment plan- Decrease fear and shame

  • Learn to manage stuttering

  • Transfer newly learned behaviors, emotions, and attitudes to daily life situations and maintain them.

Exploring and Changing Stuttering

• Understanding your 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.

• Clinician models voluntary stuttering to strangers.

• Discussion of listener reactions to clinician’s voluntary stutters.

• Client enters situations, studies her stuttering as it occurs.

• Discussion of feelings about her stuttering, listener reactions.

• 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

• Often considered challenging at first, but can have significant 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

  • Eliminated any potential for the listener being surprised by their speech

  • Minimized fear that the listener would somehow discover that they had been trying to hide that they stutter.

• 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

  • 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)

• When I produce a strong or a very intense pretend stutter, with significant stuckness in the first syllable, I feel the following:

  • Both physical and emotional relief at the end and softer part of the word/sound.

  • Almost as if something very tense in my body and my mind, which was stuck, has been released.

  • The physical relief is felt mostly in the chest, the neck, and around the mouth.

  • The more intense the stuckness in the beginning, the greater the relief.

  • If it’s very intense, it almost feels as if my brain confuses it for a real stutter.

  • Regardless of my (or my brain’s) interpretation, the tension in the chest and neck are real.

  • Lastly, although in the beginning there’s no relief, mostly tension—there’s some satisfaction because you are creating the stuckness and you control it.

Increasing Approach Behaviors

• In this step, the client should learn how to:

  • Reduce avoidance, self-consciousness, and shame about their stuttering through further “approach” activities

  • Use feared words (words with sounds they fear they will stutter on)

  • Enter feared situations

Maintaining Improvement: Becoming Your Own Clinician

• Using handout from textbook, clinician teaches client to become own clinician.

• Help client to learn to set her own goals and develop her own assignments.

• Client becomes her own clinician gradually over the course of therapy.

Other Stuttering Modification Strategies

• Developed by Charles Van Riper (1973)

Tutorial Videos

Preparatory set

Sometimes called easing-in

Used when 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)

• You are a ‘walking museum’ of all you learned to avoid and have spent life trying to hide “ugly” stuttering

• This leads to struggle and more stuttering.

• Little by little, ARTS will help strip away habitual hiding behaviors to move towards comfortable, joyful communication.

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

• Suppression of feelings

• Suppression of thoughts

Stuttering Struggle Disfluency effects

Avoidance Reduction Therapy (ARTS)

Efforts to control Stuttering → Struggle → Disfluency → Negative thoughts & feelings → Unhelpful coping strategies → Avoidance & Tension & Lack of expression → Shame & Fear → False roles

The goals of Avoidance Reduction Therapy for Stuttering (ARTS) are designed to decrease struggle and its consequences. Comfortable disfluency will remain.

Support

• The “power of the group”- Role models

  • Accountability

  • Healthy competition

• Giving and gaining support equally valuable for promoting change

• 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

• Comfort in Communication

• Confidence in Communication

• Spontaneity in Communication

• Joy in Communication

• Authenticity in Communication

Values

NOT VALUED:

Fluency (fairweather friend)

Control (any sort)

Hiding stuttering well “Practice”

Protecting others from discomfort

HIGHLY VALUED:

Comfortable, forward moving speech

Struggle-free speech

Exercising choice- way you stutter

Revealing yourself as a person who stutters

Change between sessions

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 bloc

• 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 (From More Than Fluency chapter 9; Amster & Klein, 2018)

• Becoming an expert on your stuttering pattern

• Helpful versus unhelpful behaviors

• Stuttering Fingerprint

• Desensitizing to (tolerating) open stuttering

• Stuttering directly on the feared sound/word

• Planning to feel shame per the fear hierarchy * Approaching and entering feared speaking situations
  * 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

• “Ugly” stuttering (may skip)

• Voicing on block (reinforce any sound)

• “Clean stuttering”

• Stuttering that is free of linguistic and physical escape and avoidance behaviors * 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 nervousness

    • Stuttering Modification

Peel Back the Onion

• Identify all the things you do to hide your stutter (“tricks”)

• Rank from least to most used

• Label as helpful and unhelpful

• 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.) * Not minimizing difficulty, but planning for it, and celebrating it

  • Need rationale

  • Planning for ** takes away some of its power

  • 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) $(Azios, 2020; Gerlach and Subramanian, 2016)$

• 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

• Stuttering across cultures

• 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

Outcomes

• (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 for Adults who Stutter

Controlled Fluency #1

• Guitar (2025) ***This is not meant for most clients, but for those rare clients who come to us with little fear of stuttering, 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 very controlled style and then gradually change that controlled fluency into spontaneous fluency.

Controlled Fluency #2

• Learning controlled fluency involves these skills:

  1. Flexible rate—being able to slow down speech rate enough so that stutters are eliminated.

  2. Pausing—putting in pauses at natural places so that the speech production system has extra time to process.

  3. Easy onsets—beginning a word in a very slow and easy manner so that stoppage and tension do not occur.

  4. Light contacts—touching the articulators very gently, without full stoppage so that tension does not occur.

  5. 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

• Australian Stuttering Research Centre, 2003

• 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 evidence that Camperdown can be effective but many many participants found it difficult and/or uncomfortable to use PS outside the clinic $