Multidimensional Approach: Incorporating the Cognitive and Dialectical Behavioral Therapy Shades of Stuttering into Stuttering Therapy – Michael Sugarman

Michael SugarmanAbout the Author:

Michael Sugarman is a pioneering advocate and activist in the stuttering community and in 1977, co-founded the National Stuttering Project now known as the National Stuttering Association (NSA). A former medical social worker for 35 years, Michael played a key role in establishing International Stuttering Awareness Day in 1998. Through his advocacy and leadership, he has helped advance greater awareness, acceptance, and empowerment for people who stutter worldwide

As a Medical Social Worker for over 35 years, I used both Cognitive Behavioral and Dialectical Behavioral Therapies (CBT/DBT) in my practice.  I am also a person who stutters and was the co-founder of the National Stuttering Project, currently, the National Stuttering Association (NSA). This paper blends those experiences.   It encourages Speech Language Pathologists, who treat people who stutter, to apply CBT and DBT skills in therapeutic settings for those who stutter. 

This multidimensional approach is uniquely poised to address the numerous ways that stuttering impacts individuals’ lives. 

When looking at the “shades” of stuttering, the condition is rarely viewed as a single, uniform experience. Instead, speech-language pathologists and organizations—like the International Stuttering Awareness Day (ISAD) community—view it as a broad spectrum that encompasses different clinical origins, audible sound patterns, and hidden emotional experiences.

Cognitive Behavioral Therapy (CBT) and Dialectical Behavior Therapy (DBT) are highly effective, evidence-based psychological frameworks used to treat the emotional, cognitive, and social components of stuttering. While traditional speech therapy focuses on the physical mechanics of speech production, CBT and DBT target the underlying psychological stressors that amplify disfluency, addressing what the stuttering community calls the “shades” of the experience.

Use of CBT and DBT in Stuttering Therapy Groups

Cognitive Behavioral Therapy (CBT) and Dialectical Behavior Therapy (DBT) principles in stuttering therapy groups help members challenge negative self-talk, stress, anxiety and manage intense emotional reactions to blocks or dysfluency. (1) Stuttering therapy groups provide children, adolescent and adult who stutter to share experiences and communication skills aimed at fostering positive attitude as a PWS. 

CBT techniques work as follows:

    • Cognitive Restructuring is a core technique that helps individuals identify and challenge negative thought patterns, ultimately leading to more balanced and constructive thinking. This process involves recognizing unhelpful thoughts, examining their validity and replacing them with healthier alternatives. (2). 
    • Behavioral Experiments involves structured activities designed to test and challenge negative beliefs. These techniques can be applied to group members’ negative views on their speech.  They help individuals confront their fears and reduce anxiety associated with stuttering, ultimately leading to increase skills in verbal communication and confidence. (3)  
  • Shared Desensitization combining CBT techniques and speech therapy is a powerful approach designed to reduce the stress, social anxiety, shame, and avoidance behaviors associated with stuttering. Rather than aiming to “cure” the stutter itself, this combined framework aims to decouple the physical act of stuttering from the distressing emotional response it often triggers. (1)

DBT techniques work as follows:

  • Distress Tolerance techniques are designed to help PWS manage emotional pain and focus on accepting reality. These skills help PWS cope when a person experiences stuttering, blocking, or word finding. (4)
  • Mindfulness & Acceptance techniques focus on being present and accepting reality in experiencing stuttering, blocks or repetitions without judgement. Skills help PWS to reduce emotional reactivity, speaking anxiety, and word avoidance. (1,5,6,7)
  • Interpersonal Effectiveness helps PWS manage social anxiety, emotional burden, and communication blocks associated with speech disfluencies.
  • Reducing Social Anxiety helps PWS to identify anticipatory anxiety and fear of negative evaluation. Mindfulness and acceptance techniques teach PWS to accept these feelings without letting them completely derail communication.
  • Asserting Communication teaches PWS to use structured frameworks to ask for accommodation, or conversational space without sacrificing self-respect.
  • Managing the Emotional Response lowers the emotional charge around a block and may prevent secondary behaviors like tension or avoidance. (8,9)

Use of CBT and DBT in Individual Stuttering Therapy

While individual stuttering therapy focuses on strategies to improve communication skills, increasingly CBT and DBT are recognized effective therapies in addressing both the psychological and emotional aspects of treatment in stuttering therapy. CBT and DBT help individuals manage stress related to speaking and develop coping strategies, ultimately improving communication and emotional well-being. (1) 

CBT techniques work as follows:

  • Psychological Focus helps manage stress, anxiety and social anxiety linked to stuttering by changing negative thought patterns and reducing speaking avoidance. 
  • Coping Strategies helps manage stuttering by addressing anxiety, negative thought patterns, and avoidance behaviors associated with     speech disfluencies.
  • Comprehensive Approach combining Speech-Language Pathology and CBT targets both the physical mechanics of speech and the emotional components of stress and social anxiety tied to stuttering. (1,10,11,12)

DBT helps PWS manage emotional distress, stress, anxiety, and social avoidance linked to speech challenges. DBT teaches sets of techniques that address the psychological burden of stuttering (7,9)

DBT techniques work as follows:

  • Mindfulness helps individuals stay in the present moment rather than anticipating a block or replaying a difficult speaking moment in their minds. It encourages noticing physical tension and speech thoughts without immediate judgment. (13)
  • Distress Tolerance teaches acceptance and coping skills for moments of intense communication frustration, social embarrassment, or anxiety during speaking situations (like public speaking or phone calls).
  • Emotional Regulation assists in identifying, labeling, and changing unwanted emotional responses, helps to reduce stress, shame, anger, or sadness that can accompany a stutter. (14,9)
  • Interpersonal Effectiveness equips individuals with tools to communicate, set boundaries, and assert themselves, countering social withdrawal and avoidance common in adults who stutter. (15)
  • Reduces Avoidance techniques from psychology and speech therapy, “Opposite Action” is a core concept from Dialectical Behavior Therapy (DBT) that directly pairs with Avoidance-Reduction Therapy for Stuttering (ARTS). It refers to the deliberate practice of identifying a fear-driven urge to hide stuttering and intentionally doing the exact behavioral opposite. Techniques help individuals stop avoiding words, sounds, or social situations, which often leads to more open communication. (16,17)
  • Multidisciplinary Approach works as a powerful complementary approach to traditional speech therapy for stuttering by targeting the emotional distress, anxiety, and social avoidance often tied to speech disfluency. (9)
  • Radical Acceptance in stuttering means acknowledging your speech patterns without judgment, which paradoxically creates a stable foundation for genuine communication change. Acceptance is not resignation or a belief that you cannot improve; it is an active state of mind recognizing that stuttering is a present part of your life. Much of the exhaustion of stuttering comes from fighting the block, hiding disfluencies, and fearing judgment rather than the stuttering itself. (18)

A final “shade” in stuttering therapy can include that of DBT therapy.

A new way of talking about the use of DBT techniques for people who stutter can be taken from recent articles on neuroinclusive DBT, which applies DBT to individuals with autism or other neurodivergent abilities.  (9,19,20,) Similarly, “Stuttering-affirming Dialectical Behavior Therapy” would merge DBT techniques to foster radical self-acceptance and reduce the emotional burden of masking, by adapting techniques that may help speakers navigate communication challenges, cope with situational communication anxiety, unmask safely, and advocate for themselves. (21). 

Thank you for reading my paper on the various shades of stuttering therapy within the CBT and DBT lens.

References

  1. Mongia, Monica, Anindya Kumar-Gupta, Aishwarya Vijay and Raja Sudhu. (December 11, 2019). “Management of Stuttering Using Cognitive Behavior Therapy and Mindful Meditation” Ind. Psychiatry Journal 28 (1) 4-12.
  2. https://positivty.org (April 15, 2026) “Cognitive Restructuring” The Positivity Team 
  3. Farroway, John (June 14, 2012). “How Cognitive Behavior Therapy Helped Me” https://Stamma.org 
  4. https://wwww.dialecticallbehavioraltherapy.com “DBT Distress Tolerance: Exercises, Videos and Worksheets
  5. American Institute for Stuttering (July 19, 2019). “Mindfulness for People who Stutter 4 Guided Meditations” https://www.stutteringtreatment.org 
  6. Goss, Jennifer, (March 12, 2026). “Radical Acceptance in DBT: What it means and how it can help you cope”, www.springhealth.com 
  7. Blomgren, Mike (June 10,2013). “Behavioral treatment for Children who Stutter and Adults who Stutter: A Review. Psychol. Res. Behavior Management (6) 9-19.
  8. https://www.dialecticalbehavioraltherapy.com “DBT Interpersonal Effectiveness: Exercises, Videos, and Workshops.  
  9. https://stutteringhelp.org (June 24, 2025). “Season 7 Episode 8 Podcast Counseling Approaches Mini-series with Dan Shaw DBT” 
  10. Fry, Jane (Fall, 2009). “Introduction to Cognitive Therapy” https://www.stutteringhelp.org.
  11. Menzies, Ross, Mark Onslow, Anna Packkman, and Sue O’Brien (September 2009). “Cognitive Behavioral Therapy for Adults who Stutter: A tutorial for Speech Language Pathologists” Jr. Fluency Disorders Vol. 34 Issue 3.
  12. Scott, Lisa “Implementing Cognitive Behavior with School Aged Child” https://stutteringhelp.org
  13. Arney, Megan, Jason Moser, Bridge Walsh and J. Scott Yarus. (May 2, 2025). “Trait Mindfulness and Experience of Stuttering” American Jr. Speech Language Pathology Vol. 34 1978-1991.
  14. Hurwitz, Hanan (January 21, 2025). “Stuttering-From Shame and anxiety to confident Authenticity” https://www.stutteringtherapyresources.com.
  15. https://www.upbility.net (April 7, 2025). “Understanding Stuttering in Autism-Strategies for Support and Therapy” 
  16. https://www.sisskinstutteringcenter.com ”Avoidance Reduction Therapy for Stuttering” (ARTS).
  17. https://www.behaviroalpsychstudio.com “Opposite Action”.
  18. Reeves, Lee (July 19, 2023). “Acceptance of Stuttering: One Stutterer’s Perspective” https://www.stutteringtherapyresources.com 
  19. https://GrowththruChange.org (January 19, 2026) “What is Neuroinclusive DBT” Blog.
  20. Strang, Melissa and Joseph AE Sakdalan (December 15, 2025) “Neurodiversity Affirming Dialectical Behavior Therapy Informed Group Skills Training for Autistic Adults: A Pilot Study” https://journals.sagepub.com 
  21. Greene, Stephen “Doing Something Results in “Doing Less” about stuttering. This is not the same as doing nothing” https://www.sisskinstutteringcenter.com 

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Comments

Multidimensional Approach: Incorporating the Cognitive and Dialectical Behavioral Therapy Shades of Stuttering into Stuttering Therapy – Michael Sugarman — 17 Comments

  1. Hello. I work in stuttering intervention as a practitioner, not as a
    clinician. Reading this, three questions came up that I would like to
    ask — and I would also like to leave them for other readers.

    1. Is what you describe here a therapy, or a protocol?

    2. Beginning an intervention is difficult. What I find harder is knowing
    when to withdraw. If there is only intervention and no withdrawal, then
    the process itself is incomplete.

    3. A person’s understanding is built from the environment, family and
    education they grew up in. Any intervention changes how they see their
    own speech. And when they go back to that environment, a conflict can
    appear: inside the training, when they block, people wait; back in daily
    life, when they block, someone hurries them. How is the person supposed
    to handle that?

    I would be glad to hear your view.

    • Thank you for your comments:
      these are two therapies we use in Behavioral Health/Mental Health- Evidence based and effective therapies Cognitive Behavior Therapy(CBT) and Dialectical Behavioral Therapy(DBT)- Approximately 20 – 40 weeks for a client to learn skills to reduce social anxiety, anxiety and depression – such as CBT Reframing thoughts -we use Catch it, Check it and change it- or in DBT Opposite Action and Radical Acceptance. Both use mindfulness skills-
      Also, some in the field of stuttering therapy use – Acceptance Commitment Therapy.
      Hope that helps-

  2. Hi Michael – it’s so great to have you contributing to the ISAD conference. Your perspective as one of the pioneers in the self help movement and from the mental health field is so important.

    What do you think has been one of the greatest improvements in the therapy world for people who stutter?

    And conversely, what is an area that you’d like to see more emphasis or change?

    Pam

  3. Michael, this is such a helpful summary of CBT and DBT principles as it relates to stuttering therapy. Thank you for your long-standing advocacy and for sharing your wisdom in such practical ways!

    • Thank you for your comments- I decided to write a paper rather than talk about CBT and DBT. Hope you found it useful.
      I attempted two times Mcguire, MD DSM 5 and having Biden as VP and then President to find support from stuttering community insurance coverage for stuttering therapy through Behavioral Health Parity Section-Overlapping Behavioral Support: While the core speech fluency treatment is rehabilitative, the anxiety, social avoidance, or emotional trauma associated with chronic stuttering may involve co-occurring mental health support (such as cognitive behavioral therapy or talk therapy), which is fully subject to behavioral health parity rules. Was not successful. However, i read insurance coverage pending in Illinois for stuttering therapy–Good luck- always Michael

  4. Pam,
    thank you for your kind comments.
    I feel stuttering therapists are integrating therapies used by behavioral health therapists: for example- Trauma Informed Care, Cognitive Behavior Therapy,Acceptance Commitment Therapy,Use of Mindfulness, Person Centered Care and a SLP talked about Dialectical Behavior Therapy. These therapies have been found to be effective in reducing social anxiety and (anxiety, depression and PTSD).
    Also, emphasize combination of stuttering affirmative therapy with the above mentioned therapies. Latest in Neurodiverse community is combining neuro affirmative therapy with DBT. I used that model for the end of this paper by integrating stuttering affirmative Therapy with DBT. The history of stuttering affirmative therapy is rooted in the stuttering self help movement- example what we do in mental health combine disability/mental health affirmative therapies–which was rooted in disability independent living centers and mental health peer movement.
    Hope this hopes-

  5. Michael, thank you for providing such insightful information about the role of CBT and DBT in speech therapy. You shared such valuable information and practical techniques that clinicians can use in their practice.

  6. Michael, thank you for your contribution. Articles like this are needed to help SLPs open to stutter-affirming care take the next steps toward implementation. I am especially appreciative of your highlighting DBT and hope more therapists will give it a more thorough look.

    • I agree. For example, I will share with you that Stuttering Affirming Therapy combine with DBT are complementary: From a modern psychiatric and mental health @clinical perspective, the intersection of (stuttering affirmative therapy) rooted in Disability-Affirmative Therapy (DAT) and Nero inclusive affirmative therapy planted by disability ILM, mental health peer movement and stuttering self help movement evidence-based modalities like CBT, DBT, TIC and ACT represents a crucial evolution in mental health care.
      Today, progressive mental health therapists view (stuttering affirming therapy)DAT and NIAT as an essential framework that shifts focus toward empowering vs. curing recognizing that many mental health challenges stem from minority stress, systemic ableism, and an unaccommodating environment, rather than personal “brokenness”. Within this framework, TIC, CBT, DBT, and ACT are not discarded; instead, they are heavily adapted to affirm the patient’s lived experience.
      In stuttering example: A new way of talking about the use of DBT techniques for people who stutter can be taken from recent articles on Neuro inclusive DBT, which applies DBT to individuals with autism or other neurodivergent abilities. (9,19,20,) Similarly, “Stuttering-affirming Dialectical Behavior Therapy” would merge DBT techniques to foster radical self-acceptance and reduce the emotional burden of masking, by adapting techniques that may help speakers navigate communication challenges, cope with situational communication anxiety, unmask safely, and advocate for themselves

  7. Hello Michael,

    I just wanted say a big Thank You to you for writing this paper. The messages and the wisdom are of crucial importance to the community, both PWS and therapists.

    Take care.
    Hanan

  9. Hi Michael, I am currently completing my masters program and am intrigued by your research on CBT and DBT and its implementation. Your paper discusses using CBT and DBT techniques to address the emotional and psychological impacts of stuttering. I was particularly interested in how these approaches could be implemented with children who stutter, since techniques may need to be adapted to a child’s developmental level. Could you provide examples of what incorporating CBT or DBT principles into a pediatric stuttering therapy session could look like, and how you would help children develop these skills in an appropriate way?

    • Thank you for your comments– Here’s a tool box for you- DBT, CBT, and Play Therapy Toolbox for Children and Adolescents: Over 200 Worksheets and Activities to Address Anxiety, Depression, Trauma, … Motivation, Family Dynamics, and More
      by Amanda K. Crowder (Author), Julianna Elsworth (Author), Anastasia Harmeyer (Author)
      Hope this helps–Warmly Michael

    • Follow up to your request: CBT (Cognitive Behavioral Therapy) and DBT (Dialectical Behavior Therapy) are evidence-based talk therapies used to help children and teens manage emotions, thoughts, and behaviors, though they target different needs and intensity levels.

      Cognitive Behavioral Therapy (CBT)

      • What it is: A short-term, goal-oriented therapy that focuses on the connection between thoughts, feelings, and behaviors. It teaches kids to identify and challenge unhelpful or distorted thinking patterns.
      • Best for: Anxiety, depression, OCD, phobias, and mild-to-moderate behavioral or ADHD challenges.
      • How it works for youth: Therapists use playful, age-appropriate tools—such as thought-tracking worksheets, role-playing, or exposure exercises—to help children realize that changing how they think can change how they feel and act.
      • Research impact: Studies show CBT achieves a high rate of symptom reduction and remission for youth anxiety and depression.

      Dialectical Behavior Therapy (DBT)

      • What it is: An intensive adaptation of CBT that balances acceptance (validating current emotional pain) with change (learning new behavioral skills).

      • The Four Core Skill Modules:
      1. Mindfulness: Staying grounded in the present moment without judgment.
      2. Distress Tolerance: Getting through a crisis (using tools like temperature changes or paced breathing) without making things worse.
      3. Emotion Regulation: Understanding, naming, and shifting intense emotional spikes.
      4. Interpersonal Effectiveness: Asking for needs to be met and managing conflict while keeping self-respect.
      • Role of Parents: Unlike standard individual therapy, programs for adolescents (DBT-A) or children (DBT-C) heavily involve parents or caregivers in skills training and family sessions.

      Key Differences at a Glance

      Feature CBT DBT
      Core Focus Changing negative or unhelpful thoughts Balancing emotional acceptance with behavioral change
      Typical Issues Anxiety, worries, depression, mild behavior issues Self-harm, intense mood swings, severe impulsivity, chronic crisis
      Structure Usually individual sessions, goal-oriented, shorter-term Often combines individual therapy, group skills class, and phone coaching
      Family Involvement Varies; parents updated or included as needed Frequently requires active parent/caregiver participation

      More details on framework breakdowns can be explored via the Child Mind Institute Guide on DBT or academic overviews on NCBI / PubMed Central.
      If you’d like to narrow this down, let me know:
      • The age of the child or teen
      • What specific behaviors or feelings you are hoping to address
      I can share which approach is typically a better fit or how to find a qualified specialist.
      •
      AACAP
      Psychotherapy for Children and Adolescents: Different Types
      Different types of psychotherapy: * Dialectical Behavior Therapy (DBT) can be used to treat older adolescents who have chronic sui…
      •

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