For the 2007 ISAD conference, I presented a paper describing seven principles of stuttering therapy based on my 30+ years of professional experience and specialization in treating school-age children and adults with fluency disorders. The focus of this paper is to clarify and expand on some principles based on feedback I received from many people who asked questions or made comments about the principles I described. I appreciated all the feedback I received about my paper and thought it would be helpful to revisit and share some additional information about some of the principles.

Principle #1: No Two Persons Who Stutter Are Alike

The principle emphasizes that each person who stutters is different and a treatment approach that seems best for one person will not necessarily work with another. Treatment must be tailored to the needs of each client such that each client receives a unique blend of strategies and approaches that are relevant to their current needs. Clinicians need to consider evidenced-based procedures and methods (Bothe, Davidow, Barmlett, & Ingham, 2006) as well as use their own clinician judgments and intuitions in planning and implementing treatment.

Principle #2: Stuttering Therapy is More Than Teaching Techniques

This principle suggests that most clinicians tend to focus too much of their time in treatment on strategies and techniques to improve fluency skills or modify stuttered moments. It is understandable that most clinicians will spend a majority of treatment time on changing speech behaviors because this is what clinician feel most comfortable doing in therapy. The problem with focusing on techniques is that they only address the motor-skill training portion of the fluency disorder. Thus, rather than focusing all efforts on achieving higher levels of fluency or modifying stuttering, it's been my experience that it is more productive to help school-age and adult clients focus on a combination of improved speech skills with improved knowledge, understanding, perceptions, feelings, and attitudes about his or her stuttering.

Somewhat related to the topic of technique use was a question raised in response to last year's paper concerning the use of personal electronic devices that alter the frequency of a person's voice and/or delays the auditory feedback of speech as a means of reducing or eliminating stuttering. A device such as the SpeechEasy can produce dramatic reductions in stuttering with initial use and for several weeks/months afterwards but it should not negate the need for working on a client's feelings, attitudes, and perceptions about stuttering.

The use of the SpeechEasy should be made with caution given the findings from a recent study by O'Donnell, Armson, and Keifte (2008). They found that there is considerable variability in how people who stutter will respond to the device and it is difficult predict who will and who will not benefit from using the device long term. In another study by Armson and Keifte (2008) they found that the speech rates of people who stutter using the SpeechEasy device were well below normal speech rates, which could produce unnatural sounding speech. Thus, the pros and cons of using the SpeechEasy need to be discussed with each client but clearly, additional research is greatly needed on the long-term effectiveness of this device. It should also be pointed out that the device does not seem suitable for children who stutter who are below the age of 15.

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

The CALMS model (Healey, Scott Trautman, and Susca, 2004) serves as the foundation for this principle. This principle generated considerable discussion and questions. Many readers wanted more information about the clinical application of the CALMS model and a more thorough discussion of the model and a copy of the article that explains the model. That information can be found on my website at www.unl.edu/fluency/clinician.shtml) along with other information clinicians might find helpful. The CALMS model accounts for individual differences found among people who stutter and the accompanying rating scale for school-age children who stutter provides a profile each client's cognitive, affective, linguistic, motor, and social (i.e., CALMS) abilities.

Several readers last year were curious as to how the model can be applied to treatment. First, is should be recognized that one of the main features of the model involves the complex interaction among the five factors that account for why stuttering might occur in a given speaking situation. With this in mind, the first step would be to assess a client's performance in each of the five CALMS areas. Then, the clinician can devise a plan of therapy that will address areas of performance in each component that need attention. For example, let's say a clinician discovers that a client has considerable negative feelings or high anxiety about stuttering and stutters with a moderate degree in most speaking situations. Treatment could focus on the use of voluntary stuttering to help the person analyze and learn what he/she is doing during a stuttering moment (cognitive and motor components) along with discussions of how it feels to stutter in an easier, more open way (affective) while talking about something familiar or topics with various levels of complexity (linguistic component) with someone who understands stuttering, like the clinician (social component). I encourage clients to stutter openly with me before I have them stutter with people they don't know. In this way, I am addressing cognitive, affective, and motor components simultaneously. Certainly, one could spend a lot of time therapy time on one component such as the affective or motor aspects of stuttering but the focus would be to bring about a collective understanding of how one component affects every other component directly and the function of each component can change depending on the speaking situation.

Principle #4: Help People Who Stutter Accept Their Stuttering

The basis for this principle is rooted in the change in attitudes and perceptions of the person who stutters about his/her stuttering behaviors. People who successfully manage their stuttering accept it for what it is and don't let it rule their lives. This is an important message for children and their families. Stuttering should not define the child or adult who stutters. Treatment for children and adolescents who stutter needs to be a positive and supportive experience meaning that working on fluency techniques ad nauseam may not be productive and could turn the child off to therapy. Readers last year wanted information on how to help children and adults accept their stuttering. Strategies might include helping the child learn as much as he/she can about stuttering from books/article on stuttering or the stutteringhomepage website, learning about famous people who stutter, having an open and frank discussion of the emotions and negative feelings about stuttering, coming up with a plan for how to deal with teasing and bullying, and having the client understand that there isn't a "quick fix" to the problem.

Principle #5: Treatment for Stuttering Takes Time

Both client and clinician need to understand that the treatment of stuttering can take considerable time in order to see improvements in the stuttering. This can be a difficult concept for parents or clients to understand and accept because they want the stuttering to disappear quickly. It's our job as clinicians to help parents and families understand that change takes time. We might not see a rapid and dramatic reduction in stuttering frequency, particularly when the fluency disorder has existed for many years. However, 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, making self-corrections in his/her stuttering, and stuttering with less tension and effort.

One way to address the "how long will this take?" question is to have a frank discussion with the adult client or parents of a child who stutters about their expectations of therapy and what can be reasonably accomplished in a relative short time frame versus long-term. I also like to address the client's willingness to devote time and energy to working on their stuttering outside of the treatment setting. If a client doesn't practice what has been learned or fails to complete assignments, then one can predict that improvements in the stuttering behavior will take much longer to achieve.

Principle #6: Clients Have to Want Therapy

This principle focuses primarily on the treatment of middle school and high school students who stutter. Many times there is resistance to continue with therapy for this age group because they have lost hope that the stuttering will go away, despite many years of therapy. During the teenage years, therapy seems to be low on their list of things to do because most do not want singled out as being different. While going to therapy might have been tolerated in elementary school, it is no longer "cool" to be in therapy as a teenager. A large majority of teenagers will wait until they are out of high school to pursue treatment again, where the stigma of being different in the eyes of peers is not as prominent.

In response to a few questions about this principle of therapy from last year's paper, I indicated that it is important to not make the child feel guilty about wanting to discontinue therapy or no longer wanting to work on his/her stuttering. The children might not want to continue but I tell them they are welcome to come back when they need more help. I also like to have a discussion with them about how they will handle various social situations (e.g., being teased or bullied about their stuttering, interacting with peers, talking on the phone, etc.) Talking through these situations and doing some problem solving would be an important step prior to the termination of therapy. The bottom line is that children have to be ready to make changes before any therapy is going to be effective. Becoming more fluent may just take too much mental and physical effort than the client is willing to provide.

I got a few questions last year about how to counsel parents when their child no longer wants to be involved in therapy. Parents need to appreciate and respect their child's decision that he/she no longer has the motivation to work on his/her stuttering. Because parents want to help their children anyway they can, they feel an enormous sense of frustration when they see their child reject available help. If parents force the child to continue in therapy, it will only result in more resistance and a waste of time for everyone concerned. Unfortunately, there isn't anything a parent or clinician is going to do that will make a difference. I focus on counseling parents to be patient, understanding, and focus on the positive things the child does or can do, rather than his/her stuttering. I also try to reassure the parent that treatment is available at any time the child wants to return and some day the child will probably be interested in getting back into therapy at some point in the future.

Principle #7: You Are Never Too Old To Learn

The last principle is a reminder that one never quits learning about stuttering and how to be a better clinician. I have learned a great deal from every client I have treated. Reading the literature on stuttering and attending conferences that focus on stuttering research and therapy are important continuing education activities. Research indicates (Arndt and Healey, 2001) that clinicians feel they have a lack of knowledge, skill, or confidence in knowing how to go about treating stuttering. There is nothing wrong with clinicians being honest and acknowledging that they don't know how to treat a particular fluency disordered client. There are specialists that are willing to help and these individuals can be found on websites that list board recognized specialists in fluency disorders (BRS-FD) and those who have advanced training obtained from attending one of the Stuttering Foundation's workshops. It is imperative that clinicians refer clients to those who are qualified to treat stuttering or ask for advice from a specialist in fluency disorders if a clinician is uncertain about any aspect of providing services to those who stutter.

Armson, J and Kiefte, M. (2008). The effect of SpeechEasy on stuttering frequency, speech rate, and speech naturalness. Journal of Fluency Disorders, 33, 120-134.

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.

O'Donnell, J.J., Armson, J., and Kiefte, M. (2008). The effectiveness of SpeechEasy during situations of daily living. Journal of Fluency Disorders, 33, 99-119.

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