About the authors:
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Dr. Grossman has extensive experience as a teacher, researcher, and clinician. Before joining AIS, she was the clinical services coordinator at Hofstra University and an adjunct professor at Long Island University, Mercy College, and Queens College. In addition to fluency disorders, her teaching and clinical experience has focused on childhood language and learning disorders, autism spectrum disorders, and language development. Heather received her doctorate degree in 2008 at the University of Louisiana at Lafayette. |
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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.
Children
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.
Thanks for a great paper, and importantly a pragmatic paper for PWS and clinicians. I could not agree more with the statement that solely concentrating on physical techniques can re-enforce the belief that stuttering is somehow negative and something to be avoided. This had always been my problem with fluency techniques. Having that strong foundation of self-acceptance and belief makes that ‘flow’ you talk about all the more easier to get into.
I also noticed that the advice for kids section includes using self-disclosure and educating others about stuttering ( which i thinks great ) How do you find the parents react to the use of self-disclosure and the move away from purely speech tools?
Thanks, James. To answer your question, it tends to vary quite a bit from one kid/family to another. When we focus our discussions with kids and parents on the impact of stuttering, we demonstrate that we’re focused on long term outcomes. We find that many parents are amenable to ideas of self-disclosure and education, but when they aren’t, that gives us some clinical information about the parents. In those cases, we might need to work further with the parents on acceptance.
I think my clinic follows a very similar philosophy to that of AIS. Much like the reaction we get from people who stutter themselves, some parents embrace it and others have great difficulty making that shift. My biggest struggle is giving the family (or the client) space to come to their own conclusions about what to focus on in therapy and which treatment objectives will result in the best outcomes in the long-term. I have a tendency to want to convince my client of the importance of other treatment objectives (ex. increasing knowledge of speech/stuttering, reducing avoidance, improving overall communication skills, etc.). It may take a little patience, but instead of “telling”, it’s best to provide them with opportunities to figure that out through their own experiences. Anyone else have as much trouble with this as I do? 🙂
Nice to hear from you Brooke. I think its common for therapists to feel this way. I know I have. Just like I often remind my clients, therapy is often a marathon, not a sprint! In the last few years, I’ve been asking my clients more and more to do “noticing work.” Often, the client will observe things about their internal or external experience of stuttering that I wouldn’t have known or expected.
Thank you Heather. It’s encouraging to see the field moving away from using speech tools, especially for children. I’m not sure about the concept of telling a child “they are the boss of their own mouth.” Bosses control (well, not good bosses, but you get what I mean). I found that the less our son focused on his speech, i.e. controlling, the less he struggled. The more he tried to control his speech, the more he struggled and the quieter he became. I always encouraged our son to self-disclose, but he always refused. It seems like such a good idea! He’s off to college now and doing great — but I still hope he’ll eventually incorporate self-disclosure into his communications.
Hi Dori. I agree that seeking “control” can be very dangerous since this translates commonly to “do whatever you have to do in order to not stutter” When we tell a child he is the boss of his own mouth, it is in the context of he or she coming to learn that he has the ability to say what he wants to say ( and if stuttering is a part of that message, that is just fine!) and that he also has the ability to speak in different ways- We have the child contrast loud/soft voice, high/low pitch, bouncy stutters/stretchy stutters, etc. and make a point not to suggest that any one way is superior. Rather, we praise the child for playing with different ways of talking and making a commitment to BE HEARD, stutter and all. In that way he is boss (“no one is going to keep you from talking!”)
Thanks for that answer Heather — I was thinking you meant the child could/should control what’s happening. That’s definitely different from feeling empowered to say whatever he wants to say regardless of any tension.
This is a question for Dori- When you say “speech tools”, are you referring to only speech modification strategies or are you referring to stuttering modification strategies as well. I think your son is most definitely not alone in that the more he tries to control his speech, the more he struggles. However, do you feel that working on identifying/releasing tension or “staying on the sound” (the crux of most stuttering modification strategies) was detrimental to him as well? I’m a firm believer that, for most people who stutter, there needs to be significant amount of work done in educating, desensitizing and reducing avoidance BEFORE a person can successfully make changes to how they stutter. However, I do believe stuttering modification strategies/activities can be beneficial when a person is ready for them (emphasis on WHEN). I often find stuttering modification works hand in hand with acceptance. Once a person can tolerate stuttering (or some stuttering), overall tension decreases and makes it easier for the person to make some changes to the way they stutter, potentially decreasing the tension even more. I’m curious as to what your son’s experience was with working on stuttering more comfortably and if you feel as strongly against these type of strategies/activities as well.
Hi Brooke — thanks for your question. I’m not familiar with “staying on the sound” as it relates to stuttering modification therapy. I’m referring to anytime you ask a child to think about their speech in order to not make speech errors – whether that’s speech modification strategies or elements of stuttering modification strategies or even fluency-shaping techniques. I think you hit the nail on the head when you say “can be beneficial when a person is ready for them.” I believe very few children are ready, either developmentally or emotionally, to change the way they talk in order to not stutter – or stutter less. The approach you’re talking about can maybe be helpful for teens and adults, but can too easily backfire with children. What I feel most strongly about is that both parents and speech therapists understand that real harm can be done. Our son became silent, withdrawn, depressed, had sleeping issues, all by the time he was nine years old. I’m not suggesting that this was all connected with his stuttering and the therapy he was receiving, but I have no doubt that the therapy approach contributed to this spiral. His stuttering went from mild to moderate to severe and these secondary behaviors became far more detrimental than the stuttering itself. We changed our focus from speech tools to keeping him talking and engaged. It took a few years to get him back out of his shell, but we did it. You might want to check out my book – Voice Unearthed: Hope, Help, and a Wake-Up Call for the Parents of Children Who Stutter for the whole story…
Dori-I can imagine how frustrating that was to be spending time and money in efforts to help your child only to watch him struggle more. When I asked you about stuttering modification strategies, I’m referring to activities aimed at helping to reduce some of the tension or maladaptive avoidance/escape behaviors associated with stuttering moments so that the person can speak more freely, whether or not they stutter. Much of these activities are referenced above by the the AIS folks (see “playing around with stuttering.”). I was just curious if your son’s therapists had included a component like what I described as it sounds like most of the treatment that your son received was more speed modification (fluency-shaping type strategies). I wholeheartedly agree with you that putting pressure on a child to use strategies in order to not stutter or stutter less can result in increased tension and secondaries in an attempt to hide or avoid stuttering.
P.S. I already have a copy of your book 🙂
Hi Brooke — I think that “playing around with stuttering” would be less risky with pre-teens and teens than with school-aged or younger children. They are more developmentally mature to differentiate between “playing around” and “this is what I think you should do.” — especially when they hand out all those stickers for using those techniques (see my paper from ISAD 2013). Glad you have the book — hope you find it of value in your journey…
Best,
Dori
Brooke and Dori— thanks for creating such an interesting and meaningful conversation. Dori, thanks for emphasizing not only the impressionability of children but also highlighting that their developmental maturity may make physical changes, in the traditional sense, unrealistic. I give your previous ISAD article “The Right Time to Break Out the Stickers” to parents who may not quite understand the risk of sending the wrong message to children when trying to create physical changes. And more importantly, how these demands can snowball further in a direction we never intended they go (i.e. altering self-esteem, confidence in their ability to communicate well, etc.).
We do feel that many children are able to make physical changes to the way they stutter and the way they communicate; however, most of this is through indirect work. Working on things like Heather mentioned above (i.e. eye-contact, volume, fearlessness in speaking with new people, talking about stuttering, etc.) can help facilitate the direct change that you’re inevitably working towards. By increasing confidence and decreasing anticipation/ negative attitudes, we tend to see a natural reduction in physical tension as well as willingness to “play around with stuttering.”
Hi Sara – I thought I had responded to this, but I don’t see anything. I’m so honored that you’re giving out my 2013 paper to parents. I know parents can be challenging and insistent on doing everything possible to make this go away (as I was), but parents can also be educated of the risks and I believe most will get it. I wrote the book that I wish I had read prior to engaging in speech therapy with Eli. I now have a Voice Unearthed Facebook page which is quickly gaining momentum as parents and therapists from all over the world are resonating with the messages in the book. I hope you’ll join in…
Best,
Dori
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What a welcome change! We are trying out these very ideas for sometime…Focusing on overall communication, listening for ex. Etc. Congrats onyour good work..
And congratulations on your wonderful work with TISA in India! Say hi to Dhruv for us!
Hi all,
You wrote a very interesting paper. As a stutterer, When I started my way out from silence.I needed to change my stuttering habits, i couldnt comunicate with “silent blocks , so i needed first to learn what happen when i cant make no sound and to learn basicly how to stutter with sound.Only after it i could start desensetize my stuttering and changing my stuttering to more clean stuttering.Now,my fear is lower then ever,but i feal that i still tensing a lot somtimes,and it is probably an habit that i will need also to change and it wont demenish by itself.So after the long interduce: my qustion is: how do you know if the tension and the struggeling will dimenish by itself or that you will need also to work on stuttering modification tools to change the “long years stuttering habits”?
Or maybe my story is rare and in most cases you need only to work on the fear and the avoidance?
Thanks
Ari
geashono@gmail.com
Ari- I think as a person who stutters myself I find it’s a mixture of the natural variability of stuttering and also stuttering’s way of showing me what I could still work on. Your question is a hard one to easily answer because I think everyone’s experience can be different. Maintaining a degree of desensitization is probably the most important aspect, as you mentioned. Until we are comfortable letting our stuttering out, most attempts at physical modification will be like putting a band-aid on a deeper-rooted issue, making changes volatile and often short-lived. However, I do believe once we’re working simultaneously on becoming more comfortable, accepting, and even fearless with our own stuttering, that we can also play around with modifying it physically if we’d like. As we’re exploring how and what we’re going to do to make changes to our physical stuttering, circling back to our intention is important. Maintaining a goal of forward-moving speech, not the goal of masking or avoiding stuttering helps insure we don’t send ourselves the wrong message. We try and take a broader perspective on “stuttering modification” tools here at AIS, where we consider whatever you’re doing to make the moment of stuttering more forward moving, counts. So doing things like “getting onto that next sound” where, for example, we could focus on moving from, “c-c-c-c-coffee,” to “c-c-o-o-ffee,” as a way of working through a block that seems to keep us at the front of the word until we feel we can push the rest of the word out. Or simply, playing around with tension levels intentionally to show ourselves that we have the power to change how the actual moment of stuttering presents. And of course, some do find traditional stuttering modification techniques to be helpful too, just remember to check-in with your intentions—it’s up to the individual to explore. Hope these ideas help!
Thanks Sara,it defiantly makes sense.
Ari
geashono@gmail.com
I am currently a graduate student in North Carolina but will be graduating in May 2015 with my MS in Speech-Language Pathology and venturing out on my own soon thereafter. This is my last semester of classes before going into my internship and I am taking a class about fluency. Since I am learning all about this, I really enjoyed reading your article and found all the tips quiet helpful. I like how you said to encourage the child to play around with his/her stuttering and help them understand “they can be the boss of their mouth.” I am currently doing clinicals at a elementary school and I am finding that children face a lot of tension, not so much from themselves but from other children. How would you address the situation if the child was being bullied for stuttering and therefore was scared to explore his stuttering?
Emily
Hi Emily, thanks for your comment. I’m glad you enjoyed the article. I think its important to help the child differentiate between bullying, teasing, and questioning. When bullying is truly happening, its important to connect with the student’s teachers and parents (maybe even administrators) to come up with a game plan.
If the child is experiencing teasing or questions from other students, I like to spend time talking with the child about several options for responses. We even put it all in a chart. We write down the comment or question they got from a classmate, and then we write down several potential reactions, good or bad 🙂 We then add a column and write down the result from each of those reactions and the child picks one or two good options. This conversation often needs to happen more than once, and it can be furthered with role-playing, story-writing, etc. I also like to spend time reading books about stuttering with kids, and “Stuttering Stan Takes a Stand” is a good one on this topic.
Thank you so much Carl. This is really helpful. Bullying really upsets me and I wasn’t sure my role in the situation as an SLP. I want to advocate but did not want to embarrass the child in anyway or over step my boundaries. I think your examples are a great way to advocate for the child but from the backseat. I will definitely be taking these into consideration when the issue arises, as I am sure it will.
Emily
Thank you Carl, Heather and Sara for an excellent paper! I find myself constantly returning to similar ideas about addressing awareness inward and externally. I am also passionate about addressing bullying and it’s devastating impacts for everyone and most certainly our youth.
When previously working with adjudicated inner-city youth, there was a requirement for the students to work SODAS multiple times a week. SODAS were written out Situations where the students developed three Options to the situation and the Disadvantages and Advantages to each of these options and ultimately the Solution based upon the reflections of each option. It sounds like this might be a similar concept to your game plan that you explained. We saw first hand how empowering this was to the youth, even when their solutions weren’t necessarily the most favorable outcomes.
I am curious if creating a game plan like this is something that you work with your clients in regards to everyday situations especially considering your (impressive) focus on mindfulness?
Thank you for sharing your knowledge and work,
Bree
I am also a Graduate student, in my first class focusing on fluency, and I felt that this article was extremely relevant to the topics that we discuss in class. There is a lot of focus on therapy and management that is not speech modification, but rather acceptance and identification. I am learning that this is really the most important step of fluency therapy. Since I anticipate working with children, I enjoyed the techniques you presented for children, such as having the parent create a slower and stress-free communication environment. Also I think that by having the child learn to self-disclose from an early age, will help them become more confident in their speech from an earlier age. I like the strategy of having a child “play around with stuttering” by having them try different types of stuttering (prolongations, bouncing, increased and decreased tension, etc.). I think this is a good way to let the child have fun with their stutter, while desensitizing it at the same time. My question to you is, have you ever encountered a situation where because of this “playing around” the child then develops a new habit of stutter. For example, if they usually have blocks, then after this exploring of different types of stuttering they start to prolong? And if so, is this seen as a progression? Does it have any influence on the next step in therapy?
I am also curious how to approach the topic of children getting bullied. If they are progressing in therapy, and receiving positive reinforcement from their clinician that gives them confidence to step outside of the box. But when they finally work up the courage to use these techniques outside of the session, and they immediately get shut down, I feel like this would do a lot of damage to their progress. Also what if the child is working on self-disclosing that they are a person who stutters, and they then get bullied and teased by their classmates because they were public about their stutter. In the child’s mind I feel like they would think they were better off not talking at all. How can you control the reactions from the other children in order to not discourage your client?
Great paper team. I see the struggle of therapy in the future is to adapt beyond what is taught in university in terms of treatments and also personal client goals. You have suggested some interesting thoughts in terms of treating adults and children, many of which are already in play around the globe with some therapists and clinics. I think desensitization for CWS is essential and understanding that stuttering is not wrong (or illegal). Also I like that fact that you mention building up strong basic communication skills for these kids. Strong communication skills go so far beyond speech alone. We know some very effective communicators who stutter openly and form some in an uncontrolled fashion.
For adults you have also raised some great points. I love to deconstruct stuttering situations with friends to help them to understand the totality of the faced situation. Good paper
Hi Heather, Carl, and Sara!
I am currently a communication disorders graduate student working with middle school students in the school district. I was very eager to read your paper about the different ways I can approach working with fluency and found this to be very helpful. I think we are often so involved in getting students to either “feel fluent” or “feel comfortable and in control” of their fluency that we don’t think about the difficult feelings and emotions speaking can bring on. I never thought about how general public speaking could improve how PWS feel about their speaking skills.
On another note, as you all know, working in a school district is difficult enough as it is, and I see these kids once a week for 30 minutes on an individual basis, but as soon as I leave at the end of the semester, I’m sure these kids will go back to seeing the SLP 30 minutes/week in a group. What are your opinions on using these alternative techniques in a group setting versus an individual setting in kids this age? Do you think it’s better to see them on an individual basis or could they benefit from sharing about their fluency/dysfluency with one another? Would it be another way for us to decrease the negative behaviors if the discussion came from a peer in a similar situation?
Thank you so much for this refreshing view on fluency therapy!
We like to start with kids on an individual basis, but try to get them into a regular or intermittent group with other kids their age after a few sessions with the child. I would say, try pairing up the kids for a session or two and you’ll know pretty quick if its good for them or not. More often than not, its an awesome experience.
I really enjoyed this article and think I will find it very useful in my future as a SLP! It caught my eye right away that the importance of use in real-life situations is of utmost importance because I think this should be one of the main goals of most types of speech therapy. This semester in my fluency class, we have spent a lot of time talking about the counseling aspect of fluency therapy including changing the negative beliefs. It was interesting and exciting to see that others are discussing and learning the same approaches!
Allyssa
I am another graduate student who enjoyed reading this article. You suggest for teens and adults to explore public speaking and working on improving those skills. I recently attended a NSA group meeting with teens. It came up in the meeting that one of the girls, a junior in high school, had it in her IEP that she did not have to give speeches in class because she felt uncomfortable with her stuttering in front of the class. She had expressed her plans for college, but I couldn’t help but wonder- how will she give speeches in her college classes if she is not currently doing so? My question to you all is, do you think that this is harmful to the girls future success in college? Should she be required to give at least one speech in front of the class to practice her speaking skills? Thank you very much for this informative article.
Megan
Hi Megan,
I’ve seen different students take different routes with public speaking. Clinically, I try to encourage my clients to think long term. Using this girl as an example, it might help her avoid discomfort and embarrassment now, but is she preparing herself for public speaking in college? And if she somehow gets around public speaking at the college level, what will she do once she’s working? A lot of people have told me they chose a job because they thought it wouldn’t require a lot of talking/public speaking, and it turned out they had to face that demon after all. So, you can see my stance here. Its ultimately her decision, but I think its best to think long term with things like this. For some other options for navigating public speaking in school, check out this resource on the Stuttering Homepage – https://www.mnsu.edu/comdis/kuster/Infostuttering/college.html. Its an email thread from Stutt-L about public speaking considerations for college students who stutter, but I think many of the ideas can be applied to high school students as well.
Hello,
Thank you for the wonderful therapy ideas and objectives. They are really wonderful, and they supplement the information we are currently learning in my fluency course quite nicely.
I am currently a grad student, placed in the public school setting this semester. In settings where a “fluency percentage goal” is the norm, what would you suggest SLPs use as rationale for the above mentioned objectives (for insurance and other purposes)? I really love them and feel that they would be a welcomed change in the public school system as compared to “Johnny will be 80% fluent.”
Thank you again,
Melinda
Hi Melinda,
Great question. It all depends on what you chose to measure in the person’s experience with stuttering. Impact is just as measurable as percent stuttered syllables, and its significantly less variable. When you measure %SS, you’re getting a snapshot in a clinical setting. If you’re measuring a child’s perceptions, functional behaviors, emotional reactions, etc… you’re truly looking at impact. If you need norms for insurance or IEPs, use the Behavior Assessment Battery (Vanryckeghem & Brutten) or the OASES (Yaruss & Quesal) forms in order to make a case to work on things other than fluency. Hope this helps!
Thank you for such a great paper and for the excellent resources. I like how you reshaped the objectives to focus more on changing negative beliefs. I am interested to know the reaction that you feel from the children and from their parents when you provide feedback about them “stuttering well.” Is this something that you discuss first and then use throughout all treatment tasks? Do you find that using this phrase is positively received?
Thank you,
Anica Gillis
Hi Anica,
Its not often expected, but it is often positively received. Though, we need to make sure we provide rationale for stuttering more easily. When its not positively received, that’s often evidence that the parent needs to be working on acceptance themselves, and that becomes part of the therapy experience.
Carl
As future clinicians, a graduate classmate and I were wondering how difficult it is to make the children or adults comfortable with self-disclosure to others?
Its a challenge but worth it. Some things to consider:
1) Readiness is a really important consideration. And we think its important to never ask your clients to do anything you wouldn’t do your self. If they’re uneasy or unsure, maybe they’re ready to try it and maybe they’re not. A good place to start is by doing it yourself and have them watch (call up a pizza shop and say, “I-I-I have a question, but a-a-a-as you can hear, I-I-I ssssstutter, so hang in there… What time do you close on Sunday?”). If they’re still not ready, do it again, and again.
2) self-advertising is an art form, it takes time to get good at it, and its important to explain that we’re not having them call pizza shops because that’s the best place to advertise. We’re doing it simply for practice so they can consider how it might best apply to their own life.
3) rationale, rationale, rationale – its helpful to provide an explanation for self-disclosure. There’s a lot of available reading on the subject. In fact, several peer-reviewed articles on the topic.
Thank you very much! We will definitely take that into account with future clients!
-Keri & Shauni
I had commented this earlier, but I’m afraid I replied to someone’s post instead of starting my own…
I am also a Graduate student, in my first class focusing on fluency, and I felt that this article was extremely relevant to the topics that we discuss in class. There is a lot of focus on therapy and management that is not speech modification, but rather acceptance and identification. I am learning that this is really the most important step of fluency therapy. Since I anticipate working with children, I enjoyed the techniques you presented for children, such as having the parent create a slower and stress-free communication environment. Also I think that by having the child learn to self-disclose from an early age, will help them become more confident in their speech from an earlier age. I like the strategy of having a child “play around with stuttering” by having them try different types of stuttering (prolongations, bouncing, increased and decreased tension, etc.). I think this is a good way to let the child have fun with their stutter, while desensitizing it at the same time. My question to you is, have you ever encountered a situation where because of this “playing around” the child then develops a new habit of stutter. For example, if they usually have blocks, then after this exploring of different types of stuttering they start to prolong? And if so, is this seen as a progression? Does it have any influence on the next step in therapy?
Hi Arielle, that’s a good question. I think it depends on intention. We have to be cognizant of our clients’ intention with playing around with their stuttering, and help them understand that we’re stuttering in different ways in order to learn to stuttering more easily, desensitize, reduce secondary behaviors, remove negative stigma, improve forward movement of stutters, etc… we’re not playing around with stuttering as a way to avoid stuttering or to be more fluent. If a child is using their new version of stuttering as a way to avoid stuttering, we take that as clinical information and spend more time talking to the child about avoidance. We might also spend more time playing around with moments of stuttering, making it more of an intentional act rather than a habitual pattern. Additionally, if the child is using a new version of stuttering only on words that are feared/anticipated, that could be a problem. We want to play around with the moment of stuttering, but also insert voluntary moments of stuttering on non-feared words as well.
Wonderful ideas, and so appreciated! I love the natural context ideas for therapy that you mention. As a graduate SLP student in my first Fluency course, I recently observed an SLP with an elementary child in a fluency therapy session. On the way to the session, the young girl very candidly explained her stuttering to a peer (it made me smile). What age do you typically recommend to begin working on self-disclosures?
Thank you,
Cammi
Hi Cammi,
I provided an answer below 🙂
Hi All! Thank you for a wonderful paper and for providing alternative therapy methods to the traditional “physical management” strategies. It’s a refreshing idea that is reminiscent of what I recently heard from a PWS who told me that far too often clinicians focus on perfecting skills in the therapy room that only fail to help in the “real world.” This paper addresses various aspects that I believe help to provide a more holistic therapy approach to prevent that from happening. As a current graduate student, I will strive to keep your alternative objectives in mind with stuttering therapy! Thank you!
Carol
The PWS you spoke with told it true! This is a huge reason for our therapy philosophy here at AIS.
Thank you for your suggestions on therapeutic alternatives for stuttering therapy. I used to be an elementary school teacher and am now a graduate student working to become a SLP. I like the idea of teaching students to self-disclose and educate others about their stuttering. But what about for younger children (preschool, kindergarten) who may not fully understand or aware that they stutter? What should these children do when other children ask them, “Why do you talk like that?” Should teachers and SLP’s still attempt to encourage them to self-disclose and educate others? Or should the educator attempt to step in and talk to the other kids for the child who stutters?
Thank you in advance for your reply!
Hi Linda, thanks for your question. I think advertising can take different forms depending on the age, maturity, and level of awareness of the child. With pre-schoolers and kindergarteners we often discuss with them through role-playing (with puppets, etc.) possible responses to the question, “why do you talk like that?” if we feel it is appropriate (i.e. they’ve shown some degree of negative awareness or even curiosity). However, we typically don’t overdo it with children this young, especially pre-school age if they appear to be completely unaware. Acknowledging there are different ways of talking (some people talk loudly, some have accents, some have a higher pitch voice, etc.) and playing around with talking by assuming different volumes, rates, and voices, allows the child to not feel so different. In turn, they feel more able to answer that question without feeling like they are being singled out. Often, when children get asked that question it’s coming from a place of lack of understanding, not teasing. So when we encourage kids to explore talking and communicate confidently, they feel more readily able to explain what’s going on to their peers in a way they feel good about. We also feel very strongly about educating the child (to their level, of course) what is involved in talking and what we think is involved in stuttering (i.e. the brain) to show them it’s not their fault. We’ve had children come back and say, “I told Susie it’s just the way I talk and it’s a little different but I was born this way.” Or, “it’s something my brain does to my talking sometimes…it’s called stuttering.”
As for involving the teachers, I think educating them is just as important. They may need to step in if teasing is escalating, however if at all possible we like the child to feel empowered to respond. The more we open up about stuttering and make it ok to talk about, the less “awful” it becomes for everyone involved.
I thought I’d provide more information for my question about self-disclosures. The young student (female) is 7 years old. A peer asked her why she was going to speech. The young girl replied, “to get help with my stuttering.” This led to the next question, “What is stuttering?” The girl responded in a matter-of-fact manner, “it’s when I say two words at a time.” Was this response appropriate? Would you offer any other suggestions? Thank you!
Hi Cammi,
I’ve had similar experiences with a few kids of the same age. It sounds like this 7-year-old did a great job of explaining stuttering in a matter-of-fact way! Yes, I would definitely bring it up in the session, praising her of course for talking about her stuttering in such an intelligent/brave manner, and talk about her options for talking about stuttering. It sounds to me like you have an excellent opportunity to positively reinforce an important skill.
To answer your question about appropriate age, its a judgement call. It totally depends on the kid 🙂
Carl
Carl,
Thank you for your response. Providing positive feedback is one of the blessings I look forward to as I’m sure is the same for you. 😉 With each kiddo being an individual, it makes sense that how we move forward will be unique to each client and situation.
Cammi
Heather, Carl, and Sarah,
A long time ago I met Catherine Otto Montgomery at a SID-4 conference in San Diego. I was quite impressed by the vision that she had for American Institute for Stuttering. I am quite pleased that you have written a paper in the same spirit.
Do you agree with me that:
1. One is best served by working on changing stuttering related thoughts, feelings, and behaviors (such as avoidances);
2. Stuttering as not merely the speech, but also the thoughts, feelings, and actions associated with the stuttering experience;
3. By being fully aware of the multi-dimensional nature of stuttering, one can start working on overcoming stuttering from a variety of directions;
4. Most of the persons who stutter may never become totally fluent but the frequency and severity of stuttering can be reduced to the level where they become operationally fluent (see my website http://www.stutteringpsychotherapy.com)
5. It is important to accept stuttering and that it can be reduced in severity, to accept yourself with or without stuttering, and that direct speech manipulation can be used to desensitize the subconscious so as not to fear stuttering;
6. Shame and anxiety contribute to stuttering, but can be greatly reduced by cognitive behavior therapy especially rational emotive behavior therapy techniques;
7. You feel the way you think;
8. You can change the way you feel by changing your self-talk;
…other ideas in the book I think you will agree with. I teach my clients to:
9. Changing the way you think about yourself and about stuttering has a powerful effect on your feelings and your stuttering
10. Practice is the key to self-acceptance and fluency;
11. For the time being, at this instant, accept that you stutter the way you stutter and still can have a wonderful time on this earth.
12. With the techniques described in this book your emotions of anxiety, guilt. and shame as well as low tolerance for doing homework will dissolve.
13. Stuttering cannot, and does not have to, define you; you have thousands of other characteristics and roles to let yourself be defined by the one aspect you don’t like.
14. Stuttering cannot, and does not, make you a less worthwhile person. It cannot–in the terms of street language–make you a child of a lesser god. You can still make life a moveable feast.
Do you agree with me that the approach is similar to what you guys use?
Hi Gunars, thank you for your comment. Yes, we agree. Thanks for highlighting many of the important aspects for change. We believe strongly, similar to you, that ones thoughts and feelings affect behavior more than behavior affects behavior. That’s why we incorporate so much from CBT, REBT, and mindfulness into our practice. For those interested in learning more about this approach, check out the Stuttering Foundation for further continuing education literature.
I am a graduate student in speech-language pathology and I am close to starting my internship where I will primarily be working with people who stutter. I found the alternative objectives very helpful! I really like that the objectives focus on transference from therapy to real-life situations! I was wondering if you could explain your objective about promoting greater mindfulness before, during, and after experiences with stuttering. Do you mean teaching your clients to be more aware of how they are stuttering, where the tension is and those types of things? Thank you!
Thank you for the wonderful tools. The suggestions for working with adults are especially beneficial. I am also a graduate SLP student and I was thinking about the mindfulness. What will be the next step, after someone has become more aware of the habitual aspect of his/ her stuttering?
Thank you!
Check out Heather Grossman’s reply to Dori Lane Faulk below 🙂
Hi all! I am a speech-language pathology graduate student and enrolled in my first fluency course. We talk frequently about alternative objectives in class, most of which are mentioned in this paper. The techniques in this paper were great alternatives to traditional stuttering therapy. There are so many ways adults can apply these objectives to their everyday lives. I am particularly interested in the idea of mindfulness and self awareness during a moment of stuttering. It is important for people who stutter to be aware of their moments of stuttering and recognize what exactly was happening during that moment. What is the process to promoting or improving mindfulness during stuttering for adults? And, do clients typically respond well to this strategy?
A few people have asked about mindfulness and stuttering. Here is one of my favorite articles on the subject: http://www.stammeringresearch.org/mindfulness.pdf
When we encourage people to apply mindfulness to their stuttering, we often ask them to stay ‘present’ in moments of severe blocking and do some ‘noticing’ work.. This includes asking oneself , “was there something about that situation that made me try to NOT stutter?” “was there something I was trying to avoid?” In moments of severe blocks, clients often report a sort of out-of -body experience, and we want to encourage them to stay present, dig deep and really see what underlying thoughts/feelings/old memories might be contributing to a situation.
A cool application of mindfulness (as discussed in the article) is moving away from always assigning “good” or “bad” to events, thoughts, and feelings. Mindfulness promotes objective acceptance without always making value judgments- very helpful for stuttering management.
Hello,
Thank you so much for sharing such a practical list for clinicians to use. I am a graduate student in North Carolina and am enjoying learning about fluency this semester. (Yaruss is a very familiar name to us!)
I was curious if you had any recommendations for working with people who stutter and who also have Autism? What type of modifications (if any) would you recommend, and do you know of any people currently doing research on this topic?
Thanks so much!
Emily
Therapy protocols for clients who stutter who are also diagnosed with ASD need to be highly individualized (as do protocols for all clients!) With that said, I have found that since interpretation of social cues is often reduced and at times, there is little concern about listener reactions, we don’t always need to spend as much time time on desensitization. I have worked with many children who are clearly stuttering (often atypical- showing iterations of final syllables for example), but who have absolutely no desire to work on it. In these cases, I have found that we can actually increase their communicative proficiency (and indirectly their fluency) by working on improving specific areas of communication. I try to take a meta-approach to teaching how communication “works”, explaining that it involves skills that can be improved just like getting good at sports or musical instruments. In addition to improving conversation skills (initiating/maintaining topics, retelling events concisely with good organization and transition markers, body language, etc), it is often helpful to encourage more pausing (both between speakers and certainly between thoughts) For those who are motivated to modify their speech, the use of tangibles (like a bouncy ball to simulate voluntary stuttering or silly putty to demonstrate a pull-out) could be particularly helpful.
The Stuttering Foundation puts out some excellent educational resources and I know they do have some information on this subject. Vivian Siskind has also done some research in this area.
Heather, Carl, and Sarah,
I’m currently a Speech-Language Pathology graduate student and am taking a class on fluency. We have discussed many of the topics you have presented here, and I’ve found them very interesting. I really enjoyed reading your objectives and look forward to applying these in a clinical setting. I feel that these objectives are truly useful for clients in order to become fearless and successful communicators. In what ways do you emphasize mindfulness in your clients? I find the concept of mindfulness fascinating and would like to know of any strategies you use, in order to teach this.
Thanks!
Brie
Hi Brie, Check out Heather Grossman’s reply to Dori Lane Faulk above 🙂
I really liked your approach. It really helped me think about tackling the problem of changing a perception. I am just wondering how difficult it would be to get a parent on board with this approach. Do you have any strategies to help parents understand?
Parent buy-in is obviously very important. And as such, we need to be diligent in explaining our rationale to parents. When we focus our discussions with kids and parents on the impact of stuttering, we demonstrate that we’re focused on long term outcomes. We find that many parents are amenable to ideas of self-disclosure, education, playing around with stuttering, etc, but when they aren’t, that gives us some clinical information about the parents. In those cases, we might need to work further with the parents on acceptance.
Hello all,
I enjoyed reading your article and liked that you had tips for both adults and for children. I’m currently a graduate student in Speech-Language Pathology and am taking my first fluency class. My professor also likes to focus on changing negative attitudes on stuttering to positive ones and focusing more on what the person can do than what they cannot.
Honestly, before taking this class it never really would have crossed my mind to focus on the good rather than the bad. In today’s societies, it seems much more common to focus on the problem and trying to fix it. I was wondering, have you guys always had this viewpoint and conducted therapy in this way, or was it a method you decided to use after having worked a few years? Do you find that people who stutter make progress more quickly when they change their negative attitudes towards their stuttering? Lastly, do you know of any research that has been conducted on focusing on the client’s negative aspects of his/her communication rather than the positive?
Any feedback would be great!Thanks!
Melanie
Great question Melanie. I believe my therapy philosophy has morphed quite a bit with experience and working alongside different therapists. When I started at AIS in 2006, I was introduced to a holistic approach that was heavily influenced by fluency shaping. The therapy process often started with many of the things mentioned in our article here, but after shifting to the fluency techniques, it was often tough to get clients to buy into the value of things like voluntary stuttering and advertising.
As I’ve gained more experience, I’ve become more and more cautious about any management skill I teach a PWS, whether or not its fluency shaping. I’ve learned that there’s so much we can do with mindfulness (“noticing work”), desensitization, voluntary stuttering, advertising, and more, before we ever address a speech management technique.
As an example of that philosophical change here at AIS, we used to dedicate about half of our intensive therapy programs to teaching vocal fold management (fluency shaping) to teens and adults. A few years ago, we started reducing the amount of time dedicated to VFM, and we have now stopped teaching it to groups altogether (we still use that approach when appropriate in individual therapy). So we’re now spending that much more time on desensitization, functional communication, cognitive restructuring, voluntary stuttering, learning its okay to stutter, etc. As a result, when we catch up with a client a few months or a year after their intensive program, they’re often actually doing better instead of worse!
Thank you for the wonderful presentation! I am a graduate student and we are currently taking a fluency course. Our course has more of a counseling approach, so your presentation provides me with additional insight towards the content I am learning in class. As a future SLP, I agree with the importance of functional therapy techniques that will be carried over from the therapy room to real-life environments. Therefore, the therapeutic techniques that were presented will be very beneficial towards my future practice.
Thanks!
Sara
I am also a graduate student in North Carolina and will be graduating in May 2015. I really enjoyed reading your article and found it very pragmatic. I am in my first fluency class and I find that a lot of the techniques you offer line up with what we are currently being taught. I am hoping to work with kids and found your suggestions very interesting. What are some strategies for promoting mindfulness with children? Which techniques do you find most effective? What are some of the best ideas you have to approach and help kids handle bullying? Thank you.
Bekah
I am so glad to have come across this article. I am a graduate student and currently completing my practicum in an elementary school and have one client who stutters. I really feel like these alternative strategies are the most beneficial for the client. They seem to be more effective outside of the therapy session making it useful and practical for the client. Since I want to incorporate these strategies when working with individuals who stutter, do you have any advice on encouraging a client who may be hesitant and wish to continue in more traditional methods?
Hello,
My name is Claire Richards and I am a first-year graduate student, studying to become an SLP. As such, your tips on treating both adults and clients are very helpful. My professor has also emphasized going beyond management strategies to consider the person first before the fluency disorder. Addressing the negative thoughts, feelings, and behaviors should be made a priority in therapy to help generalize fluency beyond the therapy techniques used in the session. Obviously, directly addressing thoughts and feelings with children can be difficult since they do not always have a full grasp on the abstract concepts like many emotions, especially very young children. How do you suggest approaching the topics of emotions in therapy with children who stutter? Also, where do the writers of this article stand on making children more self-aware of their stuttering?
Thank you so much for sharing,
Claire
This was a great paper. I’m a graduate student in speech language pathology learning about stuttering. I thought this article was very helpful and eye opening. Do you think that using this in combination with giving tools for the student/adult is useful? If you are treating a child who stutters do you think it would beneficial for them to make a PowerPoint to first help educate their family?
Hey all! I really enjoyed reading this paper! In school we usually learn the “norms” of what to do with a client who stutters but often don’t know what to do when we hit a brick wall in therapy! All of these suggestions are wonderful! I do have a question though. You mention teaching to “flow” through the conversation, however I currently have a client who more often than not will revert to her old ways of cancellations, just stopping and starting the word/sentence over. How can I suggest/encourage the stopping of this method and increase the occurrence of keeping in the stutter to finish the word? Also, she is incredibly hesitant on speaking with her family about her stutter due to negative support. What can I tell her or how can I encourage her to go for it anyways and try to be open about her stuttering? I know you mentioned the survey, but she more thank likely wouldn’t be willing to do that.
Thanks for your great post!
Julia Horton
Hello all,
I just wanted to thank you each for putting this information out there. A lot of it was eye-opening for me and gave me a lot of great ideas. As a first-year graduate student, it is beneficial to read this information to put in my repertoire along with what I am learning in class. I really liked that a lot of your suggestions involved tackling the emotional side of stuttering because it is a big hurdle to overcome.
Thanks again!
-Katie
I agree with you. I think teachers and SLPs need to work together on this. People make fun of what they do not understand. If an SLP goes into a classroom and talks to all the children about stuttering it would go a long way in our war against bullying. If the other children understood more about stuttering they would be more accepting of all people who stutter as well as help educate others.
Hi all – great contribution. I’m happy to hear that a stuttering intensive program is moving away from speech targets and controls to a more holistic approach that includes mindfulness and focusing on what it means to be a good communicator.
I tried therapy for the first time as an adult about six years ago, and stayed with it for a little over two years, until I was sufficiently frustrated enough to realize that learning control techniques and fluency targets was not really what I needed or wanted.
I needed a person-centered approach that let me figure out ways to embrace myself and move towards acceptance. It always felt to me that the student clinicians I was working with were trying to fix me, and I didn’t need to be fixed. Learning that I am an effective communicator, even when stuttering, was very powerful for me and helped me reach a good place in my journey.
Thanks for writing this and sharing what works.
-Pam
Hello,
I love these ideas for use in therapy! I am a graduate student studying to be a speech-language pathologist. In speaking with many clinicians who have worked with children who stutter, I have heard that many children struggle with the motivation to make their speech more fluent. I have heard many reasons for this lack of motivation. Some are not aware that they stutter. Others don’t want to admit that they stutter for various reasons. Still others have accepted their stuttering as a part of who they are, as something that makes them unique, and they do not wish to change it. Have you run into the same motivational issues with children who stutter? If so, what do you believe to be the reasons behind it? I think the ideas presented here would be great in therapy with these clients. Rather than just focusing on fluency controls, clinicians could teach them how to be effective communicators in all areas. I think, as Pam mentioned in the comment above, that it is so important for them to know they are effective communicators even when they stutter.
Thank you!
Ashley Griffith
Hello! Thank you for your article! I am a Graduate Student at Kean University, currently taking a course about stuttering. I like the idea of self-disclosure and discussions with friends and family members , but I am not clear about WHAT exactly can they tell? The nature of stuttering is still little mysterious for professionals, so what information can persons who stutter tell everyone to be understood and supported? Thank you!
Hello! I truly appreciated this article for its’ insight in alternative therapy methods, but also the list of practical ideas to use with this concept. I am a graduate student and have been fortunate enough to have seen this type of therapy done, and I think it does wonders for the clients.
I am curious as to find out ideas for a client who stutters, but also has several cognitive delays. I have tried some of these techniques and others and continue to seem to get the “so what” stare or even not quite understanding why I am even trying something other than the same fluency enhancing techniques he has been receiving twice a week for years (the repetitive action of going through sentences working on prolongations appears to be a comfortable routine).
Thank you!
Alysha
This is a great article! I am also a graduate student working on my Masters in SLP and I am in a fluency class. I have been learning that focusing on the positive aspects of stuttering is more affective than focusing all the attention on “not” stuttering. I have the opportunity to watch a client receive therapy and she has strong blocks to the point where they last at least 10 seconds or longer and she appears to be in a lot of pain. What would be a good strategy to put in place for therapy for a client like her? I like the “flow” analogy and the focus on the forward movement of air and speech.
Thanks!
Meghan
Great article! I really like the idea of focusing on communication rather than the fluency. I also appreciate the encouragement of discussions on stuttering so that there is decreased shame for the PWS and increased awareness for those surrounding the PWS.
Thanks,
Melissa
Hi! Your article was very interesting to read. It was awesome to see something different for stuttering therapy. I am in my second year of graduate school, with a previous course in stuttering. You bring up a point with how some strategies do not generalize over to real life situations, and then bring up negative belief. When you are using the alternative ideas for stuttering therapy are you also working on the primary strategies such as easy onsets, and pull-outs? Also is using the alternative ideas approach more client specific or would you try it with anyone who stutters?
Thanks!
Jessica
I also had the same question. Are you still using the traditional strategies when using the alternative ideas? Also, I took note of suggestions in this article and really appreciate them for future use (as I am currently a student). I really appreciate this article, and I really agree with what you had to say!
Hello,
Thank you all for providing such concrete ideas for shaping a therapy plan. The vision you have laid out is a more holistic and encouraging approach which is important, especially for children. I think the greatest thing about an approach like this is that you can meet a person where they are currently at. One of the previous commenters wrote that a other things must be addressed before a client may be ready or willing to use speech tools. I currently have a client who has expressed sole interest in gaining speech tools, but I really feel that he would benefit from a more holistic approach that might help him feel more acceptance of himself and the way he communicates. I think it is important to note that a therapy plan (at least for that specific client) would not be complete without some focus on his use of speech tools. This has inspired me though to communicate the importance of a holistic approach. Thank you again!
-Meg
Thank you, Carl, Heather and Sara-
How great it is to read your paper and all the perceptive comments which have followed. Thank you for helping to spread the word that dealing with stuttering is about so much more than speech.
Jeff
Thank you for the information provided in this article. In my opinion it would seem that successful use of these alternative tools could lead to successful use of the speech tools in real life scenarios. Similar to someone who exercises in the morning being more likely to make healthy food choices throughout the day. Has there been any indication that this is the case?
Hello,
As a graduate student studying speech-language pathology, I am so pleased that we are learning the importance of these alternative strategies. I can definitely see how these strategies can not only produce success but positive feelings and attitudes as well. What is the first step you take to when implementing these strategies with clients who are extremely shy and/or closed minded to talking openly about their feelings and attitudes towards stuttering? Thanks!
-Karen
Hi Pam and Jeff,
Thanks for your comments! To all the graduate students, thank you for your comments as well. For time purposes, we are going to focus on answering questions directly related to the paper first and hope the general questions can be posed in the “ask the expert” section of the conference. We really do appreciate all of the thoughts, questions, and interest in topics brought about by our paper, and we are doing our best to answer as many as we can!
What a great and simplified resource for helping clients with stuttering! One of the things that I find difficult is that finding resources to helping clients with any disorder can be difficult, and often requires a lot of paper sifting. This would be a great little tool to print off and keep in your arsenal of SLP materials. I really liked the idea of using the surveys in both age groups, not only as a way to see how their family thought of it but also to inspire talking points. Great information, thank you!
Erika
I really appreciated your insight into using alternative therapy techniques versus goals and objectives that focus solely on fluency.
Additionally, I believe that communication partner education is crucial and if partners can help create a relaxed speaking environment and not pressure the speaker then stuttering will decrease. Support and understanding are key components to not only building trust but also confidence.
SLP’s should encourage individuals to talk, as the ability to communicate meaningfully makes us innately human. If we make stuttering less of a big deal then hopefully it will be viewed as something that is not negative.
I also agree that trying to speaking slowly and deliberately for one whole day is extremely awkward. It is not normal and is not a therapy technique that should be pushed unless the speaker genuinely talks too fast.
Thank you for your insight on alternative therapy approaches!
~ Angelina
Thanks for your post! It was wonderful to see alternative therapy ideas and how to use them with all ages. Self-acceptance and confidence is very important, as I have learned and read in many of these papers! I am curious to how parents react to this type of therapy, if they see it as us not actually working on the stuttering itself? Are they open to it or hesitant?