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 

Loading

Comments

Multidimensional Approach: Incorporating the Cognitive and Dialectical Behavioral Therapy Shades of Stuttering into Stuttering Therapy – Michael Sugarman — 48 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 helps.

  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.

    • Thank you for your comments. Hope this will be useful in your work–kindly michael

  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

  8. Thank you so much for this insightful paper!
    Do you have a suggestion for a non-US based SLT to start learning more about Neuroinclusive DBT? Like an online course, book etc?
    Thank you so much!

  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…
      •

  10. As an SLP graduate student, I’m interested in supporting the emotional side of communication. Is there any training would you recommend before using CBT or DBT techniques, and when would you involve a mental health professional?

    • Hello, Thank for your question- Stuttering can trigger anxiety and other psychological and emotional reactions, and limit participation in society. It is possible that psychological counseling could enhance stuttering treatment outcomes- I feel when you do an assessment to request LCSW or mental health professional to do a PHQ 9 or anxiety screens to determine PWS mental health.
      In regards to classes you can look PESI. https://pesi.com for classes in mental health therapies-
      Good luck and hope this was helpful–warmly Michael

  11. Hi Michael, I appreciated how your article included various ways to address how someone feels about speaking. Your explanation of “opposite action” made me wonder how you help a client take a small step toward a speaking situation they have avoided for years. How do you encourage this client without making them feel pressured before they are ready? Thank you for your time.

  12. Thank you for your question-
    Opposite action is a Dialectical Behavior Therapy (DBT) emotion-regulation skill where you deliberately do the exact opposite of what an unjustified or unhelpful emotional urge tells you
    How to Practice Step-by-Step

    1. Identify and name the emotion: Figure out what you are feeling and rate its intensity.
    2. Check the facts: Ask yourself if your emotion and its strength match the actual situation.
    3. Identify the action urge: Notice what your body and mind are telling you to do (e.g., isolate, avoid, attack).
    4. Choose the opposite action: Pick the exact behavioral opposite of that urge.
    5. Act fully with mind and body: Commit all the way—change your posture, facial expressions, tone of voice, and thoughts to match the opposite behavior.
    6. Repeat consistently: Keep doing it until the emotional wave naturally loses intensity.
    You can learn more about managing intense feelings through the Opposite Action Skill Guide or read a breakdown on Cognitive Behavioral Therapy Insights.
    Hope this was helpful-warmly Michael

  13. I really enjoyed this article! I was wondering if you have some examples of mindfullness activities that can be incorporated into stuttering intervention? Thank you!

  15. I really enjoyed this article! Do you have any resources for or examples of therapy activities which employ the DBT techniques? Thank you!

  16. Hello! I enjoyed reading this article. I’m curious, how might the use of CBT and DBT techniques differ when working with children who stutter compared to adolescents and adults? Are there any resources you would recommend that provide some examples of how these techniques can be adapted for specific age groups? Thank you!

    • Thank you for your question- Here’s a tool box you can use with children and adolescents-
      Several popular, evidence-based handbooks and toolboxes provide practical activities, worksheets, and exercises using Cognitive Behavioral Therapy (CBT) and Dialectical Behavior Therapy (DBT) for children and adolescents:

      Top CBT and DBT Handbooks & Workbooks

      • DBT, CBT, and Play Therapy Toolbox for Children and Adolescents (by Amanda K. Crowder and Julianna Elsworth): Features over 200 ready-to-use worksheets, age-adapted variations, and creative activities for anxiety, depression, trauma, boundaries, and emotional regulation. Available via PESI or Barnes & Noble.

      For adults you can use this link https://dialecticalbehaviortherapy.com/
      hope this helps- warmly Michael

  17. Hi! Thank you so much for sharing your perspective! I found it really interesting how CBT and DBT techniques can be incorporated into stuttering therapy to address the psychological aspects of stuttering. As a future SLP, I was curious about how we can appropriately incorporate these techniques into our therapy sessions. Are there specific trainings that SLPs should complete before using CBT or DBT techniques? Also, at when would incorporating these techniques fall outside of an SLP’s scope of practice? When would it be more appropriate to involve a mental health professional? Thank you again!

    • Thank you for your question– Collaboration with a mental health professional can provide anxiety and depression screens PHQ 9 or GAD will help to determine referrals to LCSW or Psychologist,
      Here’s a tool box you can use with children and adolescents-
      Several popular, evidence-based handbooks and toolboxes provide practical activities, worksheets, and exercises using Cognitive Behavioral Therapy (CBT) and Dialectical Behavior Therapy (DBT) for children and adolescents:
      hope this helps–u can learn CBT skills through Stuttering Foundation of America or DBT PESI
      MIhcael

      Top CBT and DBT Handbooks & Workbooks

      • DBT, CBT, and Play Therapy Toolbox for Children and Adolescents (by Amanda K. Crowder and Julianna Elsworth): Features over 200 ready-to-use worksheets, age-adapted variations, and creative activities for anxiety, depression, trauma, boundaries, and emotional regulation. Available via PESI or Barnes & Noble.

  18. Hi Michael! I really enjoyed how you discussed using CBT and DBT techniques to address the emotional challenges of stuttering alongside speech therapy. I wanted to know, how can SLPs help clients apply these techniques in everyday speaking situations, especially when they experience anxiety or frustration outside of therapy?

    • Hello, Thank you for your question- On a average therapy takes 20- 30 weeks to integrate CBT/DBT into daily living-
      Thank you for your question- Here’s a tool box you can use with children and adolescents-
      Several popular, evidence-based handbooks and toolboxes provide practical activities, worksheets, and exercises using Cognitive Behavioral Therapy (CBT) and Dialectical Behavior Therapy (DBT) for children and adolescents:

      Top CBT and DBT Handbooks & Workbooks

      • DBT, CBT, and Play Therapy Toolbox for Children and Adolescents (by Amanda K. Crowder and Julianna Elsworth): Features over 200 ready-to-use worksheets, age-adapted variations, and creative activities for anxiety, depression, trauma, boundaries, and emotional regulation. Available via PESI or Barnes & Noble.

  19. Hi Michael, I really enjoyed this article. You discuss using CBT and DBT to reduce anxiety, avoidance, and negative thoughts surrounding stuttering. How can speech pathologists make sure these approaches are being used to support acceptance and self-advocacy, rather than unintentionally reinforcing the idea that negative emotions or stuttering itself are something that need to be “fixed”?

    • Thank you for a really good question- Usually therapy takes 20-30 weeks combining individual and group skills training (70%) integrate skills into daily living–CBT, DBT, or Acceptance Commitment Therapy are evidenced based therapeutic skills –
      DBT acceptance and self advocacy skills would be under the module on Radical Acceptance
      Hope this was helpful– warmly, Michael

  20. Hi Michael! Speech therapy often requires a level of therapeutic support that I feel goes overlooked in many cases. How would you recommend collaborating with mental health professionals to both support the client and refer them to specific therapists when demand for a licensed mental health professional exceeds our capacity to support the client?

  21. thank you for a good question-
    By Collaborating with a Mental Health Professional- MHP can asses clients depression or anxiety or social anxiety with screens. These screens can help you to case conference with MHP for follow-up.
    hope this helps warmly Michael

  22. Hi Michael,
    Thank you for sharing your article! I especially appreciated the idea you shared about therapy separating the physical act of stuttering from the emotional response that triggers it. I was wondering how you might adapt approaches such as cognitive restructuring or opposite actions for younger age groups, such as teenagers, who may be reluctant or self-conscious about talking in a group setting? Also, what advice would you share with clients to help them generalize these techniques outside of therapy sessions?

    • thank you for your thoughtful question. CBT and DBT take approximately 20- 40 weeks of weekly individual and group therapy sessions to these skills taken from therapy to outside-
      Cognitive restructuring and opposite action are core mental health tools for children and teens. Cognitive restructuring (from CBT) changes unhelpful “thinking traps” by challenging negative thoughts. Opposite action (from DBT) changes intense emotions by doing the opposite of an unhelpful impulse.

      Cognitive Restructuring (CBT)

      • What it targets: Thoughts, beliefs, and internal “thinking traps” (like catastrophic or black-and-white thinking).
      • How it works: Kids learn to “catch it, check it, and change it” by looking for evidence.
      • Kid-friendly example: If a child thinks, “Nobody likes me because nobody sat with me,” they check the evidence (friends sat with them yesterday) and reframe it: “That person was busy today, I can ask someone else tomorrow”.
      • Best used for: Anxiety, worry, low self-esteem, and persistent negative self-talk.

      Opposite Action (DBT)

      • What it targets: Strong emotional urges that do not fit the facts or make a situation worse.
      • How it works: When an emotion pushes for an unhelpful reaction (like hiding or yelling), the child does the complete physical opposite.
      • Kid-friendly example: If sadness makes a child want to isolate and hide in their room, the opposite action is to reach out and ask a parent or friend to play a game. If anger makes them want to throw a toy, the opposite action is to take slow, deep breaths and ask for help.
      • Best used for: Big outbursts, intense anger, unwarranted fear/avoidance
      Hope this helps- warmly Michael

  23. Hi Michael! Thank you for sharing your article! I really enjoyed learning about CBT and DBT techniques. If a client has accepted their stuttering and doesn’t feel the need to become more fluent, how should that influence our approach to therapy? Thank you!

    • Thank you for your thoughtful question- I will try to answer you-
      When a person who stutters (PWS) accepts their speech and does not seek fluency, therapy goals shift from speech modification to communication confidence, tension reduction, self-advocacy, and eliminating avoidance. The focus becomes how freely and authentically the person communicates, rather than how smooth their words sound.

      Core Categories of Acceptance-Based Goals

      • Reduction of Physical Tension & Struggle: Instead of stopping or hiding stutters, goals target speaking more easily—such as using gentle onsets, slowing down slightly on hard blocks, or keeping the lips, jaw, and tongue moving without panic.
      • Elimination of Avoidance Behaviors: Targeting the hidden workload of stuttering, such as swapping out feared words, dodging phone calls, staying quiet in meetings, or using eye-contact tricks.
      • Self-Disclosure & Advocacy: Building the skill and comfort to openly tell listeners about one’s stutter (e.g., using a short, direct statement like, “I stutter, so I might take a moment on this word”) to set the stage for relaxed conversation.
      • Psychological & Emotional Resilience: Using tools from DBT, Acceptance and Commitment Therapy (ACT) or Cognitive Behavioral Therapy (CBT) to lower speaking-related shame, anxiety, and the emotional power that listener reactions hold over the speaker.
      • Real-World Participation: Measuring success by active engagement—such as speaking up in a group project, ordering food without delegating, or initiating a chat with a stranger—regardless of how many disfluencies occur.

      Examples of Modern Acceptance-Oriented Goals

      Goal Area
      Avoidance Reduction The client will participate in 3 previously avoided speaking situations (e.g., making a phone call, asking a store clerk a question) per week without substituting words.
      Self-Disclosure The client will use self-disclosure of their stuttering in at least two professional or social interactions per week to foster open communication.
      Attitudinal Shift The client will complete a pre- and post-therapy self-assessment (such as the OASES) to track a reduction in the negative psychosocial impact of stuttering on their daily life.

      draft a specific SMART goal for an adult or student client, or are you looking to explore a particular areas or avoidance reduction?
      Hope this helps warmly Michael
      •
      ScienceDirect.com
      Stuttering treatment goals beyond fluency: A non
      Table_title: 4.2. Views on therapy approach that does not target fluency Table_content: | Reasons for Endorsement (n= 22) | Theme …
      •
      Stuttering Foundation
      Basic Goals for a Person who Stutters | Stuttering Foundation: A Nonprofit Organization Helping Those Who Stutter
      Techniques: Stutter more easily with less tension and panic by slowing down during feared words, keeping lips/tongue/jaw moving ge…
      •
      SLP Now
      How to Write Fluency and Stuttering Goals for School-Age Students (Stuttering Goal Bank) | SLP Now
      Approach: Person-centered, collaborative, focusing on student values, communication priorities, and authentic communication rather…
      Show all

  24. Hi Michael,

    Thank you so much for sharing your experience! I was deeply invested in your article. As an SLP graduate student, I found learning about CBT and DBT strategies fascinating! I am particularly interested in the emotional impact of stuttering on the families of clients. In your experience, what have you found to be the most helpful strategies SLP’s have used for working with young children who have developed negative self-talk and other negative feelings about stuttering? Thank you!

  25. Good question- Will try to answer-
    Children who stutter often face intense emotional distress, social anxiety, and harsh inner critics. Incorporating principles from Cognitive Behavioral Therapy (CBT) and Dialectical Behavior Therapy (DBT) into their care helps address the psychological burden of stuttering by changing how they relate to their speech and coping with intense emotions.
    Here is how these two therapeutic approaches help children manage negative self-talk specifically related to stuttering:

    🧩 CBT: Challenging the “Inner Critic”

    CBT focuses on the intersection of thoughts, feelings, and behaviors. In stuttering therapy, it helps kids identify automatic negative thoughts (e.g., “If I stutter, everyone will think I’m stupid” or “I shouldn’t talk at all”) and reframe them realistically.
    • Catch It, Check It, Change It: Teach the child to “catch” the negative thought, “check” it against reality (e.g., Is it true that no one wants to listen to me?), and “change” it into a balanced, supportive statement.
    • Banish “Unicorns and Rainbows”: Avoid overly positive, unrealistic platitudes (e.g., “You will speak perfectly tomorrow!”), which children often reject. Instead, aim for objective truth: “I stuttered, but my friends still stayed to play with me”.
    • Behavioral Experiments: Children can test their fears in low-stakes environments. For example, a child might “intentionally” stutter to see if people actually laugh or judge them, which often acts as an effective tool for speech desensitization.

    🌊 DBT: Emotional Regulation and Acceptance

    Where CBT challenges the logic of a thought, DBT focuses on mindfulness, distress tolerance, and validation. DBT teaches a child how to live with uncomfortable situations without compounding their suffering through negative self-talk.
    • Radical Acceptance: DBT encourages children to accept reality as it is in the moment without judgment. A child learns to think, “I am experiencing a speech block right now, and that is frustrating, but it does not mean I am broken”.
    • Validation Over Correction: Before jumping straight into “fixing” a thought (which can sometimes feel dismissive to a child), DBT emphasizes validating the emotion. Acknowledging that “It makes total sense that you feel frustrated when you can’t get the words out” takes the sting out of the negative self-talk.
    • Self-Disclosure Scripts: DBT- aligned behavioral skills empower children to confidently state their needs to others. They can use a simple script: “I stutter sometimes, so it just takes me a little longer to say what I want to say”.

    🛠️ Home and Classroom Strategies for Adults

    • Change Your Language: Shift from fixing language (“Slow down, take a breath”) to affirming language (“I’m listening, take your time”), which normalizes the communication difference.
    • Model Self-Compassion: Let children hear you make mistakes and respond to yourself kindly out loud.
    To help provide the most relevant advice or resources, how old is the child, and are they currently working with a Speech-Language Pathologist (SLP)?
    •
    Hope this was helpful, warmly Michael

  26. Dear Michael – Happy ISAD. Good to see you going so strong after all these years. I would like to thank you for founding the NSP. John Ahlbach and Letting Go were a great inspiration to me in the 1990s after I discovered that the centre of the stammering therapy universe was in the USA and not the UK! I have always felt musically at home on the West Coast and so always felt an affinity with the location of the NSP. My own therapeutic journey has been a ‘long strange trip’ – Keep On Truckin’!

    • Hello Tim,
      Great to hear from you. Yes sounds of California penetrated our movement. Hope you are well and keep on truckin – Thank you for being part of this movement–warmly Michael

  27. Mr. Sugarman, thank you for sharing this. As an SLP graduate student and person who stutters, I feel strongly that some clinicians fall short of addressing stuttering holistically (i.e., the psychosocial impacts of stuttering). We should follow this approach and others that address the aspects of stuttering that have a concrete impact on quality of life, while continuing to advocate and educate about stuttering.

    • Thank you for your comments. I agree. During the month of October stuttering community has ISAD. During the 2nd week of May is USA National Stuttering Awareness Week. And other activities if interested July is disability pride month and UN celebrates December 3rd International Day for Disabled.
      Good luck in becoming a SLP and helping to change PWS lives- warmly Michael

  28. Michael, you’re one of the largest treasure chests filled with mental health wisdom, and so happy you’re still my friend and mentor after so many years. Thank you for yet another paper full of learning material. The vase I got from you is still on my table, filled with, what else, tulips. 😉

    Thanks for starting the ISAD that we now celebrate across the world, and for all you’ve done for our beloved stuttering community, and for me in person. Next stop Dec 3. 🙂

    Keep talking

    Anita

    • Thank you for kind comments. We share of our love for the stuttering community- I am so happy to have met you and continue to read about your adventures. Continue to rejoice on how many PWS and parents CWS are aware and some involved in stuttering community. Love always Michael