About the author:  Katie Gore, MA, CCC-SLP is a speech-language pathologist who specializes in stuttering. She founded and currently leads the City of Chicago chapter of the National Stuttering Association, and presented at the national conference in both 2014 and 2015. Katie runs a private practice in Chicago that focuses on stuttering and other communication disorders with psychosocial components. In 2014, she developed a curriculum for group stuttering therapy based on an ACT approach pioneered by Janet Beilby at Curtin University in Perth, Australia. She also founded the Chicago Stuttering Project, which seeks to connect children, families, adults, SLPs, and educators with the stuttering community and resources in Chicago. When she isn’t working on stuttering-related projects, Katie enjoys highly refined hobbies like yoga, video and board gaming, and reading comic books.

Early on in my work with stuttering, I had a very clear “that didn’t work” moment with one of my clients. He wanted to overcome his difficulty with speaking on the phone, so we agreed to the age-old activity of calling local businesses and having brief conversations. By facing this feared activity, he would become desensitized to it, and the fear would subside. So the books had said…

Except, it didn’t work. With each phone call, his stress visibly increased. Blocks became longer and harder. After several calls, when I could practically hear his heart pounding from anxiety, I stopped him and said, “I don’t think this is helpful.” He agreed.

As a newly certified Speech and Languge Pathologist (SLP), this experience troubled me. I certainly understood why he would be anxious and why things would go this way, but I didn’t understand how to change this experience. I didn’t know how to help him, as his SLP. What was I missing here?

Theory to practice

Fortunately, I was introduced to Acceptance and Commitment Therapy (ACT) at ASHA in 2013. ACT is a psychology and counseling framework that operates on the premise that life is uncomfortable, and rather than try to get rid of the discomfort, we should find a way to make it “workable” in our lives. Rather than changing the way I do therapy, this approach provided much-needed insight and perspective on therapy strategies that are already commonly used. Most importantly, the ACT principles have given me a new perspective regarding why challenging stuttering exercises might work, and how they can be used to even greater advantage.

ACT has six core values that can be used as goal areas, and which work together to facilitate acceptance. The following paper explains what these six principles are, and how they might be applied therapeutically in a common voluntary stuttering exercise.

Experiential learning

I recently met with a client I’m going to call “Leah” for anonymity sake. Leah and I have been working together for a few months. Her overt stutter is borderline, or mild if she’s having a rough day, but how she sounds is a big deal to her. Stuttering, to Leah, is very negative. Our main goal in therapy is not to help her stutter less, but to help her reframe her experience of stuttering so that it becomes less negative.

Value 1: Present Moment

Many times, in my first voluntary stuttering exercise with someone, they don’t have to talk at all. I do all the talking (or, more accurately, stuttering), and I tell them to watch.

“OK, Leah,” I said. “I am going to ask all these people where the closest train stop is, and I’m going to stutter, a lot. I want you to watch the other person, and then tell me what happened afterwards. Observe my moment.”

Being in the present moment is a key core value of ACT. Life is made of moments. Some are uncomfortable, some are joyous, some are painful, some are exciting, some are multiple things all at the same time. All moments pass, though. A skill developed in ACT is the ability to be in a moment, acknowledge it, observe it, and then let it pass.

With stuttering, the instinctive reflex is to get out of the moment as fast as possible. Panic mode, make it stop. Panic leads to the sensation of lost control and, more notably, lost perspective. It is very difficult to sit back and observe a moment when we are panicking.

Panic is an automatic response, and it’s pretty tough to actually obey the phrase “don’t panic”. I want Leah to see what is actually happening during a stuttering moment when she isn’t panicking. So, instead of making it her moment, I make it mine. Her job is to experience the moment of stuttering with the clarity of a panic-free experience. What might be different?

Value 2: Values

This value is one of my favorites, and works really nicely with other therapy approaches that focus on desensitization and reducing avoidance. Values is simply about identifying what is important to you, what you really want out of life. For stuttering, I often hear this stated as, “I want to say what I want to say, when I want to say it.” What prevents this from happening is not always the physical stutter itself. Most of the time, what prevents this value from being lived out is the fear of stuttering, or the fear of the consequences of stuttering. Fear leads to avoidance. In many therapy approaches, clients are challenged to reach for those things that they truly value, even if doing so is scary. This requires…

Value 3: Committed Action

In this session, I actually needed this value more than Leah. While not one of the six core values, this is another important principle in ACT: the therapist should experience and work towards goals along with the client, sharing struggles and fears.

Committed action happens after you’ve identified your values. “I want to say what I want to say, whenever I want to say it.” Then do that.

For this session, my value was that Leah be able to experience a moment of stuttering from a safe, non-panicking place. In order to do that, I was going to have to stutter a lot. This is not an easy thing, so it requires committed action.

A wonderful thing about therapy of any kind is the therapist-client relationship. This really helps with committed action. One, it is comforting to have a friendly person alongside when doing something challenging. Two, both the client and clinician can support each other during a challenging experience. I told Leah I was going to stutter, and so I had to.

This accountability partnership is key in the usual avoidance reduction activities when the client does the stuttering. The therapist challenges the client to voluntarily stutter during interactions. Often, I give people specific sentences to say, tell them to stutter on specific words, and even tell them how long they have to hold the block for. They’re scared, but committed. And they do the action.

Value 4: Self-as-context

This is always the trickiest ACT tenet to conceptualize, so I will quote Russ Harris, a chief author of ACT: the purpose of self-as-context is to “make contact with a sense of self that is a safe and consistent perspective from which to observe and accept all changing inner experiences.”[1] That still sounds a bit theoretical for the non-philosophically inclined, but I think it’s well-illustrated by the earlier panic example. Stuttering can easily be accompanied by panic. A PWS may lose their sense of self-as-context, and become completely wrapped up and defined by the stutter in that moment. They may fear that the listener will judge them by their stutter, because that’s all person who is stuttering is able to see, feel, hear, and sense in that moment.

Of course, the truth is that a stutter does not define a person. In fact, no single thing about a person can really define them. We are a mosaic of identities, beliefs, passions, relationships, joys, sorrows, experiences, memories, hopes, and goals. Working on self-as-context allows us to experience those parts that we don’t like so much (such as stuttering) while not losing perspective.

When I asked Leah to evaluate my interactions, she was very accurate. “He was really nice.” “She was kind of rushing you.” “She was pretty rude.” I’d generally agree, then say, “So, overall, how did you think that interaction went?” Every time, her answer was, “Well, you’re still here, so even if it didn’t go so well it’s not really a big deal.”

Now, I sometimes was not feeling so great during this voluntary stuttering exercise. I sometimes felt foolish, or angry, or annoyed at the people I had stuttered to, depending on their reaction. But, removed a safe distance from the experience, Leah was able to see the entire context. She saw that I made it through, that I’m in one piece, and able to move on to the next thing. The experience, the moment, was uncomfortable (present moment acknowledgment), but context helps keep things in perspective.

Value 5: Defusion

This is another of my favorite values. A common goal in ACT is “unstickying” oneself from negative thoughts, experiences, and identities. We can have them, acknowledge them, but we should not be fused with them.

I had a very personal experience with defusion during this exercise. The people I stuttered to today were an unusual bunch in that most of them actually reacted pretty negatively, which in turn made me become more self-conscious and panicky as I continued to stutter. After about five or six interactions, though, I had one listener whose reaction was so ridiculous that I nearly burst out laughing in the middle of my block (she obviously wasn’t intending to be ridiculous, so I managed to suppress it).

I asked Leah about it afterwards, and she agreed that it was bizarre. After discussing this strange response with someone else, I found myself defusing from the uncomfortable emotional experience I had attached, or “stickied” to it (to borrow an ACT phrase). This helped me reframe my thinking and separate from the discomfort and awkwardness experienced while stuttering.

Value 6: Acceptance

Acceptance. The holy grail of what so many modern therapy approaches strive for. Acceptance is complicated, though. It doesn’t mean that suddenly everything is perfect, and it doesn’t mean giving up or defeat.

Michael J. Fox’s take on acceptance very much echoes the principles of ACT: “Acceptance doesn’t mean resignation; it means understand that something is what it is and that there’s got to be a way through it.” Workability is a key concept in ACT, and facilitates acceptance. You can have something frustrating, uncomfortable, non-ideal be present in your life, as long as you can find a way to make it workable and live out your values.

I asked Leah what she thought about our interactions at the end of the session. “I thought it was helpful. I think I’m a little less scared now to stutter, this helped me see that life goes on. I still don’t want to stutter, and I don’t like stuttering, but I think I feel like things will be OK a bit more, now.”

Acceptance is a process, and Leah isn’t there yet. But that’s OK– as her therapist, I need to accept that it takes time for people to reach their goals, even if in my perfect world everyone would reach Zen nirvana after day one. Next time, Leah will do the stuttering, and I’ll watch her. She’ll have her own moments, and see what that experience has to teach her about herself.

Putting it all together

Blessed are the flexible, for they shall not be bent out of shape. — Anonymous

Despite its name, “acceptance” is not the goal of ACT. The goal of ACT is emotional flexibility: the ability to experience, move through, and live fully with the complex variety of human emotions, both the comfortable and the uncomfortable.

The most difficult speech therapy exercises can be the most liberating and life-changing.  But, sometimes the task seems so large and painful that it’s hard to see the reward on the other side. Rather than “desensitize” to the discomfort and effort required, ACT validates that “Yep, this is hard. It’s going to feel hard, and be very uncomfortable. But there is another experience waiting that makes this worth it.”

Stuttering is hard. Even when a person has come to a place of “acceptance”, there can still be moments of pain, frustration, or disappointment. Acceptance doesn’t mean eliminating the possibility of ever reacting negatively to stuttering ever again. It means sometimes you’re down, and sometimes you’re up. But through it all, you’re living life: a full life, rich with values and action.

“You can’t stop the waves, but you can learn to surf.”

References

[1] Harris, Russ. (2009).  ACT made simple. Oakland, CA: New Harbinger Publications.