This fall, I will begin my 30th year as a professor of speech-language pathology at the University of Nebraska-Lincoln (UNL). During my tenure at UNL, I have focused my teaching, research, and clinical practice in the area of fluency disorders. There are many things that I have learned over the years about stuttering and how to treat the disorder, although many years of clinical experience or years in the profession mean nothing when it comes to claiming that I have all the answers about how to treat this complex disorder. Nonetheless, I would like to share some insights that I have gained from the many clients I have treated, the parents I have counseled, and the clinicians I have taught and trained during the past 30 years. What I have learned from others can hopefully assist students and clinicians who want to learn more about a few principles of stuttering therapyŠat least from my perspective. What follows are seven principles of stuttering therapy that I believe are important to understanding the treatment of stuttering:

1. No Two Persons Who Stutter Are Alike:

Most experts in stuttering agree that every person who stutters is different and a treatment that works for one doesn't necessarily work with another. Stuttering is a multidimensional disorder that involves a complex interaction of many factors that make it difficult to change once it is firmly established. Yet, most clinicians are constantly in search of the one therapy or approach that will work with all their fluency-disordered cases. Unfortunately, their search will be futile. There are some evidenced-based procedures and methods for treating stuttering (Bothe, Davidow, Barmlett, & Ingham, 2006) but we need to learn more about why those are effective and which persons who stutter will respond best to those methods. There also is evidence that many clinicians simply feel a lack of knowledge, skill or confidence in knowing how to go about treating stuttering (Arndt & Healey, 2001). This is understandable and I believe these are the reasons that most clinicians simply focus on fluency or reducing stuttering as the main goal of therapy. This leads me to the next principle.

2. Stuttering Therapy is More Than Teaching Techniques:

The pursuit of fluency is so powerful that adult clients or parents of children who stutter will do almost anything or spend any money necessary to make a fluency problem disappear, such as purchasing an electronic device that turns out to produce only bring temporary relief or reduction in stuttering. As clinicians, we can appreciate a client's or parent's desire for fluent speech, but we also appreciate and understand the tremendous work it will take for the client to achieve that goal.

Most clinicians will do what they have been trained to do best--change speech behaviors. When it comes to stuttering therapy, a clinician's first instinct is to simplify the problem by having a client go through extensive mass practice of one or more fluency techniques so the speech becomes smoother and more fluent. However, if clinicians focus too much on fluency skills, then the message to the client is that stuttering is unacceptable and if the stuttering isn't getting better, then he/she isn't working or trying hard enough. After a lengthy period of therapy without much progress, both client and clinician become disillusioned and discouraged, and everyone begins to wonder if the stuttering is ever going to get better. Moreover, clients will soon learn that the vigilance it takes to achieve and maintain fluent speech isn't worth it, particularly when the resulting fluent speech might sound unnatural or contrived. Although Van Riper's (1973) stuttering modification approach encouraged people who stutter to become desensitized to stuttering and to learn how to reduce the severity of disfluent moments, it too has its limitations. Therefore, rather than focusing all efforts on achieving higher levels of fluency or modifying stuttering, I have learned that it is more productive to help school-age and adult clients focus on a combination of improved speech with improved knowledge, understanding, perceptions, feelings, and attitudes about his or her stuttering,

Principle 3. Approach Stuttering From a Multidimensional Point of View:

Stuttering persists because of multiple factors and finding ways to help a client manage his/her stuttering in light of these factors is not easy. In an attempt to figure out which multidimensional aspects of stuttering need to be addressed, I, along with two of my colleagues, developed a model of stuttering that addresses five key factors that are central to maintaining stuttering (i.e., Cognitive, Affective, Linguistic, Motor and Social). We called it the CALMS model and it accounts for the individual differences found among people who stutter as well as the strengths and weaknesses each person possesses among the five CALMS components (Healey, Scott Trautman, & Susca, 2004).

The treatment approach that evolves from the CALMS model is an integration of five factors that seem to interfere with allowing a disfluent client to talk in an easier way. Notice I did not say talk "fluently." Approaching therapy from a CALMS perspective allows a clinician to focus on helping people who stutter discover improved thoughts, perceptions, attitudes and feelings about stuttering so they can say what they want, to anyone, at anytime, in any place. In my opinion, an integration of these factors within a stuttering therapy program produces better outcomes than an approach that only focuses on the client's use of specific fluency enhancing or stuttering modification techniques. An example of this approach was described in an article written for the 1998 International Stuttering Awareness Day conference (Healey, Norris, Scott-Trautman, & Susca).

Principle 4: Help People Who Stutter Accept Their Stuttering.

Logically following Principle #3 is the notion of acceptance of stuttering. Acceptance means that stuttering doesn't define who the person is and that he/she can accept the realities of the stuttering without undue worry, fear, avoidance or shame. It doesn't mean the person is doomed to being disfluent forever or that he/she can't be expected to change or manage his/her stuttering. Many clinicians tell clients that it's "okay to stutter" but a client's interpretation of that statement is "if stuttering is okay why then am I being asked to change it?" This mixed signal is not something clinicians want to convey to their clients. Clinicians can help clients understand its "okay" to let go of the need to control or hide stuttering as well as any negative thoughts, feelings, and behaviors that are associated with their stuttering. When acceptance occurs, usually a client is able to talk with fewer speech disruptions.

One thing I have learned from a number of people who have successfully managed or are managing their stuttering is that they don't let stuttering rule their lives. They no longer feel helpless or ashamed that they stutter and are willing to stutter openly, are comfortable acknowledging stuttering to others, are able to stutter with less tension and effort, and no longer avoid words, people, or speaking situations. These are important components to accepting stuttering as well as an essential part of the recovery process from stuttering (Starkweather & Givens-Ackerman, 1997).

Principle 5: Treatment for Stuttering Takes Time.

Everyone needs to understand that the treatment of stuttering takes considerable time--even taking years to see improvement. This is particularly difficult for parents or clients to understand and accept because they want a quick fix to the problem. It's our job as clinicians to help parents and families understand that change takes time. We might not see a quick and dramatic reduction in stuttering frequency but we can see a person make small improvements in a variety of areas such as more positive thoughts about and attitudes toward his/her stuttering, seeing a child being more comfortable stuttering in front of others with less tension, and making self-corrections in his/her stuttering. With a clinician's help, clients should never abandon the hope of being able to manage their fluency disorder and with time and patience, some type of improvement can be made.

Principle 6: Clients Have To Want Therapy.

I have had countless experiences where parents want their child to have therapy more than the child does. This situation hardly ever results in an effective outcome of therapy. In fact, I have recommended on many occasions that services be discontinued when a child explicitly says he/she no longer wants to be in therapy as long as the child understands what lies ahead. It's at that point that I focus more attention and counseling on the parent rather than trying to convince the child to remain in treatment. Each person who stutters needs to hit "rock bottom" or reach a point where working on their stuttering is critically important in order for any treatment to be effective.

Principle 7: You Are Never Too Old To Learn.

I end with this last principle as a reminder that clinicians who treat people who stutter need to continue to learn about and understand stuttering. I have learned a great deal from my clients as well as colleagues and other fluency experts and I am still learning. I have never felt that I have figured out all there is to know about stuttering and its treatment. The current and past International Stuttering Awareness Day conferences have provided excellent learning opportunities for students, clinicians, and fluency specialists to learn more about stuttering. I trust that this article has made an important contribution to this collective effort.

Arndt, J. and Healey, E. C. (2001). Concomitant disorders in school-age children who stutter. Language, Speech, Hearing Services in Schools, 32,68-78.

Bothe.A., Davidow, J., Barmlett, R. & Ingham, R. (2006). Stuttering treatment literature 1970-2005: I Systematic review of behavioral, cognitive, and related approaches. American Journal of Speech-Language Pathology, 15, 321-341.

Healey, E.C., Norris, J., Scott-Trautman, L., & Susca, M. (1998). Enhancements to integrated approaches for treating stuttering. International Stuttering Awareness Day Internet Conference, Mankato State University, Mankato, MN.

Healey, E.C., Scott Trautman, L., and Susca, M. (2004). Clinical applications of a multidimensional model for the assessment and treatment of stuttering. Contemporary Issues in Communication Science and Disorders, 31, 40-48.

Starkweather, W. and Givens-Ackerman. (1997). Stuttering. Austin, Texas: PRO-ED

Van Riper, C. (1973). The treatment of stuttering. Englewood Cliffs, NJ: Prentice-Hall

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